CI EALING Rady EAL 16 Borough of Ealing. ANNUAL REPORT OF THE Medical Officer of Health And School Medical Officer For The Year 1925 Thomas Orr, M.D., D.SC., of the Middle Temple, Barrister-at Law, Medical Officer of Health, School Medical Officer and Medical Superintendent of the Isolation and Smallpox Hospitals. Ealing: Francis A. Perry, Ltd., 4, Kirchen Road. P.H. 68. Telephone No. 2100 Ealing. P.H 68. Borough of Ealing. Public Health Department, Town Hall, Ealing, W. 5. THOMAS ORR. M.D.. D.SC., MEDICAL OFFICER OF HEALTH AND SCHOOL MEDICAL OFFICER With the lompliments of the Medical officer of Health. EAL 16 Borough of Ealing. ANNUAL REPORT of the Medical Officer of Health and School Medical Officer for the year I 9 2 5 . THOMAS ORR, M.D., D.Sc., Of the Middle Temple, Barrister-at-Law, Medical Officer of Health, School Medical Officer and Medical Superintendent of the Isolation and Smallpox Hospitals. EALING: Francis A. Perry, Itd., 4, Kirchen Road. ANNUAL REPORT of the Medical Officer of Health, 1925. INDEX. page Acts, Byelaws and Regulations 30 Ambulances 29 Bacteriological Examinations 63 Births 14 Blind, Deaf, &c., Children 108 Cancer 19 Clinics and Treatment Centres 29 Dairies, Cowsheds and Milkshops 33 Deaths 15, 19 27 Dental Defects 85, 91 Diphtheria 48 Disinfection 34, 63 Factories and Workshops 33, 35 Food 41 Health Visiting 72 Heart Disease 26, 95 Hospitals in the District 28 Housing 37 Illegitimate Births 14 Infant Deaths 15 Infant Care and Management 68 Infectious Diseases 48, 59, 87 Maternity and Child Welfare 64 Medical Inspection of School Children 79 Medical Treatment of School Children 89 Milk 41 Natural and Social Conditions 10 Notifiable Diseases 48, 59 Nursing Arrangements 29 Offensive Trades 33 Population 13 Sanitary circumstances of the district 31 Sanitary Inspection of District 32 Scarlet Fever 49 School, Sanitary condition of 37, 78 Slaughterhouses 33 Staff 7, 77 Statistics, Vital 9 13 Statistics, General 9 Tonsils and Adenoids 83 Tuberculosis 61, 84 Uncleanliness 82 Vital Statistics 9, 13 Welfare Centre 71 — 5 — Public Health Department, Town Hall, Ealing, W.5. 31st May, 1926. To the Mayor, Aldermen and Councillors of the Borough of Ealing. Mr. Mayor and Gentlemen, I have the honour to submit to you the Annual Report for the year 1925 on the health of the Borough and on the work of the Public Health Department. This report is a Survey Report which is submitted every five years, and is therefore larger than its four predecessors. In the contents you will be able to recognise and appreciate the progress in public health work to which you have given your encouraging support in recent years. As to future developments in public health activities these will be concerned mainly with the extension of the whole public health scheme to embrace the districts of Hanwell and Greenford, which, it is expected, will be included in the Borough on the 1st October of this year. While these developments will benefit chiefly the added areas they cannot but benefit the Borough as a whole. In submitting this report I wish to express to the public health staff my appreciation of their good work and my gratitude for their unfailing loyalty. I am, Mr. Mayor and Gentlemen, Your obedient Servant, THOMAS ORR, Medical Officer of Health. — 6 — PUBLIC HEALTH COMMITTEE. Councillor W. T. White (Chairman) Alderman H. Armriding ( Vice-Chairman). Alderman H. W. Peal, J.P., Councillors E. H. Atkinson A. H. Chilton, J.P., J. C. Fuller, Lt.-Col. R. R. Kimmitt, O.B.E., J.P., and H. M. Sayers. MATERNITY AND CHILD WELFARE COMMITTEE Councillor Lt.-Col. R. R. Kimmitt, O.B.E., J.P. (Chairman) Mrs. Morris ( Vice-Chairman). Aldermen H. Armriding and H. W. Peal, J.P. ; Councillors E. H. Atkinson, A, H. Chilton, J.P., J. C. Fuller. H. M. Sayers, and W. T. White; Mesdames Cocker, Girdlestone, and Parry. - 7 - STAFF. Medical Officer of Health and Superintendent of Isolation Hospital— Thomas Orr, M.D., D.Sc., Of the Middle Temple, Barrister-at-Law. Assistant Medical Officer of Health and Medical Attendant of Isolation Hospital— Harold Ellis, M.B., B.S., M.R.C.S., L.R.C.P., D.P.H. Consultant, Maternity and Child Welfare Centre (Ante- Natal Clinic)—Part-time— John W. Bell, L.R.C.P.I. & L.M., L.R.C.S.I. & I.M. Medical Officer, Maternity and Child Welfare Centre (Infant Consultations)—Part-time— S. Grace Banham, B.Sc., M.B. Chief Sanitary Inspector— Thomas Hill, Cert. R.S.I., and Cert. Inspector of Meat and Other Foods. Sanitary Inspectors— James Stubbs, Cert. R.S.I., and Cert. Inspector of Meat and Other Foods. George W. Stevens, Cert. R.S.I., and Cert. Inspector of Meat and Other Foods, — 8 — Staff—(Contd.). Health Visitors— Eleanor Evans, Cert. R.S.I., Cert. C.M.B. (Senior). Marguerite Farrow, Cert. R.S.I., and Trained Nurse. Mildred Adeline Rice, Cert. R.S.I., Cert. C.M.B., and Trained Nurse. Chief Clerk and Committee Clerk— Harry Birrell. Clerk and Laboratory Assistant— *Ernest W. Hill. Clerks— * William A. J. Turner. Olive Levasseur. Maternity and Child Welfare Centre— 13, Mattock Lane, Ealing. Note —To the salaries of all the above officials, excepting the two marked with an asterisk, contribution is made under the Public Health Acts or by Exchequer Grants. — 9 — SUMMARY OF GENERAL STATISTICS, 1925. Population (Estimated 1925) 68,410 Population (Census, 1921) 67,755 Population (Census, 1911) 61,222 Area of Borough in Acres 2,947 Number of Structurally Separate Dwellings (1921) 14,967 Assessable Value (District Rate) £568,330 Net Produce of a Penny Rate £2,305 SUMMARY OF VITAL STATISTICS, 1925. Births:— Legitimate Males, 454 Females, 460 Total, 9141 Illegitimate Males, 23 Females, 24 Total, 47 961 Birth-rate 14.0 Deaths: Males, 302 Females, 383 Total 685 Death-rate (Crude) 10.0 Death-rate (Standardised) 9.1 Deaths of Infants under 1 year:— Legitimate Males, 28 Females, 23 Total, 511 54 Illegitimate Males, — Females, 3 Total, 3 Infant Death-rate per 1,000 Births:— Legitimate, 55.8 Illegitimate, 63.8 Total 56 Death-rate Total per 1,000 Deaths Population Measles — — Whooping Cough 3 0.04 Diarrhoea (under 2 years of age, per 1,000 births) 3 3.12 Diphtheria 4 0.06 Scarlet Fever 1 0.01 Influenza 24 0.35 Tuberculosis of Lung 39 0.57 Other Forms of Tuberculosis 13 0.19 All Forms of Tuberculosis 52 0.76 — 10 — Comparison of Vital Statistics of Ealing with those of England and Wales, etc., 1925. 105 Great England Towns London Ealing and (including Wales London) Birth-rate 18.3 18.8 18.0 14.0 Death-rate 12.2 12.2 11.7 9.1 Infant Death-rate 75 79 67 56 Measles Death-rate 0.13 0.17 0.08 0.00 Whooping Cough Death-rate 0.15 0.18 0.19 0.04 Diarrhoea (under 2 yrs per 1,000 Births) 8.4 10.8 10.6 3.12 Diphtheria Death-rate 0.07 0.09 0.11 0.06 Scarlet Fever Death-rate . 0.03 0.03 0.02 0.01 Influenza Death-rate 0.32 0.30 0.23 0.35 NATURAL AND SOCIAL CONDITIONS OF THE AREA. Physical Features and General Character of the District. The Borough of Ealing extends to 2,947 acres, and forms roughly a rectangular area one mile and a half east to west and two miles north to south. It is bounded on the north by the sparsely populated district of Greenford, from which it is separated by the River Brent, and on the south adjoins Brentford. On its east and west boundaries it has Acton and Hanwell respectively. The district is divided into two almost equal areas by the Uxbridge Road, which also divides the district roughly into two parts geologically, the northern composed of London clay, and the southern of alluvial gravel. From the southern boundary the surface slopes gradually upwards from 50 feet above sea level, to the highest point at Hanger Hill two miles due north, 200 feet above sea level, from which point it slopes downwards toward the River Brent, the lowest point at which houses are built in this region being 75 feet above sea level. — 11 — The Great Western Railway main line to Reading passes through the centre of the district, running near to and almost parallel with Uxbridge Road. The District Railway (Underground) also traverses the district, there being no fewer than five stations within the boundaries. The Great Western Railway Bicester main line passes just within the northern boundary. The Borough is divided into six wards, three north of Uxbridge Road and three south of it, all the former touching the northern boundary and all the latter touching the southern boundary. The district is almost entirely residential, factories being very small and unimportant from the occupational aspect. The factories consist of an optical instrument manufactory, a foundry, a surgical instrument factory, proprietary drugs factory, and seven steam laundries. The principal occupations of the inhabitants, as ascertained at the last Census, were as follows:- Males. Commercial Finance and Insurance (excluding Clerks) 3,300 Clerks, Draughtsmen and Typists 2,774 Engaged in Transport and Communication 2,000 Metal Workers 1,607 Professional Occupations (excluding Clerical Staff) 1,355 Engaged in Public Administration and Defence 1,270 Workers in Wood and Furniture 889 Retired or not gainfully occupied 3,619 Others 6,088 Females. Engaged in Personal Service (Domestics, &c.) 4,893 Clerks, Draughtsmen and Typists 1,915 Commercial Finance and Insurance (excludingClerks) 1,089 Professional Occupations (excluding Clerical Staff) 1,086 Makers of Textile Goods and Articles of Dress 788 Engaged in Public Administration and Defence 492 Retired or not gainfully occupied 21,507 Others 913 The great majority of those engaged in occupations are employed in London. — 12 — The lay-out of the town is well designed to give plenty of space between the houses and to preserve the residential character of the district, most of the roads being planted with trees which add greatly to the appearance and temper the air in the hot summer months. The public parks are a feature of the district. There are four large parks, Walpole, Lammas and Pitshanger Parks and the Common, consisting of 155 acres, two smaller parks of 21 acres, Hanger Hill and Cleveland Parks, the latter acquired during 1925, and several open spaces or playing grounds of 35 acres in extent. In 1925 the Boroughs of Ealing and Acton acquired for public use the beautiful estate of Gunnersbury Park, just outside Ealing and Acton, but close enough to be readily accessible by the inhabitants of both districts. The acquisition of this estate, which is 200 acres in extent, should not only preserve the amenities of both.districts, but should offer splendid facilities to old and young alike for healthful recreation. In addition to these open spaces for public recreation there are 57 acres of permanent allotments. The King Edward Memorial Hospital, which has 18 beds for men, 18 for women, 12 for children and 7 private wards, and to which 40 more beds are being added, supplies to a large extent the needs of the people of the Borough for surgical and medical treatment in a general hospital, although many cases find their way to general and special hospitals in London. For persons coming within the Poor Law the West Middlesex Hospital, which is under the Brentford Board of Guardians, the local authority for Poor Law purposes in this area, offers every facility for surgical and medical treatment. This hospital, which is well equipped and efficiently managed, is gaining in popularity every year. If the doors could be opened wider to admit a larger group of the public who are able to pay a certain amount for treatment, other general hospitals could be relieved of pressure on their accommodation and resources. There is a Dispensary in connection with the King Edward Memorial Hospital. By contributing a small amount each month, women and children of the working-class community can obtain medical treatment at their homes. — 13 - The Central Aid Society and the Ealing Philanthropic Institution do excellent work in the district by rendering assistance in many necessitous cases. The Clerk to the Board of Guardians has kindly supplied information regarding the amount of Poor Law Relief which was distributed in the Borough of Ealing during the year. This was as follows:— Money Kind Total Unemployed £3,441 9 0 £253 8 3 £3,694 17 3 Ordinary 189 14 10 296 13 8 486 8 6 Total £3,631 3 10 £550 1 11 £4,181 5 9 VITAL STATISTICS. Population. The population of the Borough in the middle of 1925, as estimated by the Registrar General, was 68,410. During the year the natural increase in the population, which is the excess of births over deaths, was 276. At the Census of 1921 the population was 67,755, and was distributed in the Wards as follows :— TABLE I. Ward. Families or separate occupiers Population. Persons per Acre. Males Females Total No. 1 or Drayton 1,868 3,388 4,147 7,535 21.7 No. 2 or Castlebar 2,730 4,254 6,651 10,905 19.5 No. 3 or Mount Park 1,858 2,839 5,153 7,992 9.4 No. 4 or Lammas 3,872 7,446 8,449 15,895 53.9 No. 5 or Manor 3,853 6,567 8,485 15,052 43.0 No. 6 or Grange 2,566 4,417 5,959 10,376 18.9 Total 16,747 28,911 38,844 67,755 23.0 — 14 — The Census returns for 1921 also indicate that there were 14,422 structurally separate dwellings occupied in the Borough, that there were 89,341 rooms occupied and that there were 1.36 rooms per person. The following Census figures indicate the increases in the population of Ealing in successive decades:— Census, 1881 15,764 „ 1891 23,965 „ 1901 33,040 „ 1911 61,222 „ 1921 67,755 The area of the Borough extends to 2,947 acres, and the density of population, or the number of persons per acre, is therefore 23.0. The gammas Ward is the most densely populated with 53.9 persons per acre, the Manor Ward coming next with 43.0, and the Mount Park Ward is the least populated with 9.4 persons per acre. Births. The number of births registered as belonging to the district during the year was 961, consisting of 477 males and 484 females. From this number the birth-rate of 14.0 per 1,000 of population is obtained. It will be seen in Table II that the birth-rate is the lowest for six years and that it is in marked contrast to the pre-war years. In the following table the birth-rate is shown to be much lower than that for England and Wales and those for the 105 Great Towns and London. Birth-rate. EALING 14.0 per 1,000 of population. England and Wales 18.3 ,, 105 Great Towns 18.8 ,, London 18.0 ,, Illegitimate Births.—The illegitimate births were 47 in number, which gives an illegitimate birth rate of 0.68 per 1,000 of population and a percentage of 4.9 of the total births. — 15 — Deaths. During the year there were 685 deaths assignable to the district, 302 males and 383 females. This number gives a crude death-rate of 10.0 per 1,000 of population and a standardised death-rate of 9.1 per 1,000 of population. The standardised death-rate is calculated by multiplying the crude death-rate by what is known as the factor for correction, 0.914, a figure which when multiplied into the crude death-rate gives a death-rate which would occur if the population in Ealing had the same kind of age and sex distribution as the whole of the population of England and Wales. This standardisation enables the death-rate of one district to be more accurately compared with another which differs from it in the proportion of the sexes and the number of persons in the various age-groups. The death-rate is low compared with those for England and Wales, the Great Towns and London. Death-rate. EALING 9.1 per 1,000 of population. England and Wales 12.2 „ 105 Great Towns 12.2 „ London 11.7 ,, Table II shows that the general death-rate has been fairlysteady during the last five years. Infant Deaths. There were 54 deaths of infants under one year of age, which give an infant death-rate of 56 per 1,000 births. This rate is very low compared with those for England and Wales, the Great Towns and London as seen in the following Table:— Infant Death-rate. EALING 56 per 1,000 births. England and Wales 75 „ 105 Great Towns 79 „ London 67 ,, — 16 — It will be seen that the rate for Ealing is 11 less than that for London, 23 less than that for the Great Towns, and 19 less than that for the whole of England and Wales. TABLE II. Showing Birth-rate, Death-rate and Infant Death-rate for Ealing for the years 1911—1925. Year Birth-rate Death-rate Infant Death-rate 1911 20.2 11.5 121 77 1912 20.6 9.7 67 1913 18.2 8.9 72 1914 17.5 9.4 59 1915 16.6 10.2 63 1916 17.0 11.1 58 61 1917 14.8 10.5 63 1918 13.0 13.6 76 1919 13.3 10.8 65 1920 17.8 8.8 47 1921 16.9 10.6 63 .56 1922 16.2 11.0 52 1923 15.6 10.6 58 1924 14.3 11.1 47 1925 14.0 10.0 56 — 17 — Table III gives the principal causes of death amongst infants under one year of age during 1925, compared with the previous seven years. It is interesting to note that of the 54 deaths, as many as 27, or a half, were due to defects at birth, namely, premature birth, congenital defects and atrophy, debility and marasmus. Diarrhoea accounted for only one death, infectious disease for three, and pneumonia and bronchitis for nine deaths. In Table IIIa, which gives the causes of death and the ages, it is seen that of the total deaths, 24 occurred when under a week old and 32 when under four weeks old, which latter figures give a Neo-natal death-rate of 33 per 1,000 births. TABLE III. Causes of Infant Deaths, 1917 to 1925. 1918 1919 1920 1921 1922 1923 1924 1925 Diarrhoeal Diseases 14 3 9 9 5 2 4 1 Premature Birth 12 13 15 10 5 11 7 9 Congenital Defects — 6 4 4 6 8 4 10 Want of Breast Milk (Starvation) — — — — - — — — Atrophy, Debility, Marasmus 11 14 14 12 10 9 6 8 Tuberculous Disease — 3 3 — 2 1 3 — Syphilis — — 3 2 — — — 1 Rickets — — — — — Meningitis (not Tuberculous) - 2 — 1 - 1 2 1 Convulsions 4 1 2 2 2 2 2 — Bronchitis 5 3 1 6 5 5 1 4 Pneumonia (all forms) 6 4 4 9 1 10 3 5 Gastritis — — 2 1 2 1 — — Common Infectious Diseases 7 1 — 7 4 2 3 3 Other Causes 13 17 7 9 15 10 11 12 Totals 70 67 64 72 57 62 46 54 — 18 — Table IIIa. Infant Mortality during the Year 1925. Deaths at various ages under One Year of Age. Cause of Death Under 1 week 1—2 weeks 2—3 weeks 3—4 weeks Total under 4 weeks 4 weeks and under 3 months 3 months and under 6 months 6 months and under 9 months 9 months and under 12 months Total deaths under 1 year All Causes—Certified. Uncertified 24 2 3 3 32 8 3 3 8 54 Small-pox - __ __ - - — _ - Chicken-pox — — — — — — - — — — Measles — — — — — — — — — — Scarlet Fever — — — — — — — — — Whooping-Cough — — — — — 1 — 1 — 2 Diphtheria and Croup - - - - - - - - - Erysipelas — — — — — 1 — — — 1 Tuberculous Meningitis - - - - - - - - - Abdominal Tuberculosis - - - - - - - - - Other Tuberculous Diseases - - - - - - - - - - Meningitis (not Tuberculous) 1 - - - 1 - - - - 1 Convulsions - - - - - - - - - - Laryngitis — — — — — — — — — Bronchitis 1 — — — 1 — — 1 2 4 Pneumonia (all forms) 1 — — — 1 — — — 4 5 Diarrhoea - - - - - - - - - — Enteritis — — — — — — 1 1 Gastritis - - - - - - - - - - Syphilis — 1 - - 1 - - - - 1 Rickets - - - - - - - - - — Suffocation, Overlying — — — — — — 1 — — 1 Injury at Birth — — — — — — — — — — Atelectasis - - - - - - - - - - Congenital Malformations 4 1 1 6 2 1 1 — 10 Premature Birth 6 1 1 1 9 — — — — 9 Atrophy, Debility and Marasmus 5 - 1 - 6 2 - - - 8 Other Causes 6 — — 1 7 2 1 — 1 11 Totals 24 2 3 3 32 8 3 3 8 54 — 19 — Causes of Death. The causes of all deaths are indicated in Table IV, in which it is shown that the groups cancer, heart disease, bronchitis, pneumonia and tuberculosis account for 91, 102, 55, 28 and 52 deaths respectively out of the total. Comment may here be made regarding the first two of these principal causes of death. Cancer.—In February, 1925, a report on Cancer was submitted to the Town Council, and a copy of this was sent to each medical practitioner with a covering letter soliciting assistance in the education of the public and in the early diagnosis and treatment of this disease. This report and letter are here reproduced. " Pubuc Health Committee." "report on cancer." “Cancer differs from most diseases with which we have to deal from a public health aspect inasmuch as we have no definite knowledge of its actual cause and very little of its predisposing causes. We possess a large amount of knowledge as to the mortality from the disease, its pathology and geographical distribution, but not much to assist in formulating fundamental principles to guide us in adopting measures of prevention. It has to be recognised that the cure of a disease may be accomplished without the actual cause being known and that the discovery of the actual cause may not always result in the discovery of a cure; but light thrown on the cause almost invariably adds to our knowledge of the means of prevention. "In various directions a large amount of research work has been, and is at present being done not only in this but in other countries. Recent research work on cancer has received a great stimulus and with co-ordinated efforts much may be done in elucidating its cause and measures of prevention. Apart from the various Cancer Hospitals and Cancer Departments attached to General Hospitals, particularly associated with research regarding cancer in this country are the Cancer Department of the Middlesex Hospital, and the Imperial Cancer Research Fund. The Ministry of Health Departmental Committee was recently formed' to — 20 — consider available information with regard to the incidence, causation, prevention and treatment of cancer, and to advise as to the best method of utilising the resources of the Ministry for the study and investigation of these problems.' The British Empire Cancer Campaign also has for its object the collection of facts regarding the disease and the institution of research if deemed advisable. Internationally the Medical Committee of the League of Nations is also engaged in accumulating information regarding the incidence of the disease in various countries with a view to elucidating its cause. "We possess no definite knowledge of the actual cause of cancer, although many views have been put forward. One fact, however, is very evident; that cancer occurs at sites exposed to irritation of a mechanical or chemical nature. For example, on the one hand cancer may arise on the tongue at the point where it is exposed to prolonged irritation by a decayed tooth or on the lip as a result of chronic irritation from smoking a clay pipe; and on the other hand exposure of workers to irritation from coal tar, paraffin, soot or arsenic may result in cancerous lesions. Whether the disease is the direct result of the irritation of the body cells or not cannot be determined, but perhaps the irritation is but a predisposing cause lowering the vitality of the cells and rendering them liable to the disease. Prevalence of Cancer. "In England and Wales with a population in 1921 of 37,885,242 persons, a total of 46,032 deaths were attributed to cancer. This means that out of each thousand persons 1.21 died of cancer. In the same year the cancer death-rate for Ealing was 1.24, being practically the same as that for England and Wales. The deathrate from cancer per thousand of population in England and Wales has gradually increased from 0.32 in 1851-60 to 1.12 in 1911-20. This increase cannot wholly be put down to an increase in the incidence of the disease for it may be due in some measure to improved diagnosis and to the survival of a greater number of persons at the later ages at which cancer commonly occurs. But the fact remains that there has been an increase. — 21 — "This increase is all the more notable as we have been experiencing substantial decreases in the death-rates from other diseases. During the period of 20 years from 1901 to 1921, in which the cancer death-rate increased by 20 per cent, the general death-rate fell by 32 per cent., that of infants fell by 45 per cent., and that for tuberculosis by 38 per cent., while substantial declines were noted with respect to most other causes of death. "The latest available returns show that the death-rate from cancer is not increasing for males up to 45 years of age and for females up to 60. The most rapid increase is occurring in extreme old age. "The following table indicates the number of deaths from cancer in Ealing for ten years compared with the total deaths. It shows that of the total deaths during these years 849, or over one-ninth, were due to cancer. The proportion is similar for the rest of the country. These are significant figures, compelling attention to the need for greater efforts being made in the interests of prevention and cure of the disease. T otal Deaths Year Deaths from Cancer 1914 672 80 1915 676 61 1916 728 80 1917 679 80 1918 880 83 1919 802 100 1920 673 74 1921 721 84 1922 747 89 1923 725 118 Total 7,303 849 "Great differences in regard to the parts of the body attacked by cancer exist between the sexes. The excess of deaths of females over males is entirely due to the disease of the breast and generative organs; in most other parts of the body a considerable excess is lecorded for males. — 22 — Susceptibility to Cancer. "In view of popular theories and beliefs I may quote the following from the Memorandum on Cancer issued by the Ministry of Health. 'It is right, however, to point out that hereditary predispositions to cancer has not at present been proved to be of any practical importance in man ; that it cannot be asserted with scientific authority that the use of any particular article of food increases the liability to cancer, or prevents it from appearing; that no known drug or preparation will prevent its appearance or cure it when present and that no danger of cancer has been proved to result from inhabiting houses or districts in which cancer happens to have been exceptionally common. There is no evidence to show that cancer is an infectious or contagious disease.' Prevention of the Disease. "Little can be said as regards definite measures of prevention excepting those relating to the avoidance of the sources of irritation already mentioned. Nevertheless, it may be assumed that the general injunctions put forward for the preservation of general health will to some extent influence the incidence of cancer. These include regular habits, regular exercise, a good mixed diet including vegetables and fruit, sound teeth, regular bowel action and the avoidance of all excesses. Treatment of Cancer. “There is only one satisfactory method of treatment and that is by complete surgical excison in the early stage before the disease has had time to extend far into the tissues of the body. Provided an operation is performed early enough a cure can be effected. Even if a complete cure is not possible owing to the disease not being recognised early enough, life may be prolonged and made tolerable by operation. “Successful treatment of cancer depends on early diagnosis' and to secure early diagnosis the public must be encouraged to seek medical advice in the early stages of the disease. This applies also to other diseases of slow onset, for example may be mentioned — 23 — tuberculosis, diabetes, chronic Bright's disease and increased blood pressure, all of which are particularly benefited by treatment in the early stages. The public must be educated generally as to the preservation of their own health and the advisability of seeking medical aid whenever anything abnormal arises. "I am not prepared to advise the issue to the public of a leaflet specially relating to cancer. I feel that a leaflet on this subject by itself, no matter how guarded it might be, would have the effect of causing alarm to many persons. What I would advise is that, if any leaflet is issued, it should relate to the desirability of calling in medical aid in all conditions of abnormal or lowered health or where there are growths or enlargements even without pain, and that the whole subject of informing or educating the public on such health matters should be included in a general scheme of propaganda which I intend placing before you at an early date. "Much is being done at the Welfare Centre in teaching the mothers to look after their health and to seek medical advice when anything abnormal occurs. The question of cancer is always born in mind by the staff, so much so that even women who are not nursing or expectant mothers usually dealt with at the Centre suspecting themselves of suffering from cancer or having suspicious symptoms, can receive advice from the consultant. Midwives, who have special opportunities of advising mothers, have also had issued to them by the Central Midwives Board leaflets giving informaton regarding cancer. Facilities for Diagnosis and Treatment. "The patient in the first instance will usually refer to his own doctor, but if he is unable to afford a doctor he can obtain medical advice from the Poor Law Medical Officer on application to the Relieving Officer. Little difficulty is experienced in the recognition by the medical practitioner of certain cases of cancer, but in others X-ray or special examination provided only at general or other hospitals may be necessary. The medical practitioror may send cases of difficulty to the King Edward Memorial Hospital, where every facility is offered for scientific diagnosis, consultants being available when required. For the Ealing area the King Edward Memorial Hospital is remarkably well equipped for dealing 24 with not only the diagnosis, but the treatment of cases of the disease, private beds being available for those who can afford to pay for them yet are unable to pay for accommodation in a Private Nursing Home. Some medical practitioners may, however, prefer to send cases to special hospitals in London. Patients in affluent circumstances will of course go direct to consultants through their usual medical attendant. "For cases coming within the Poor Law provision is made for diagnosis and treatment at the West Middlesex Hospital, where there is an X-ray department and where consultants are available. The Conference of Local Authorities called at the instance of the Board of Guardians to consider the utilisation of local facilities for the diagnosis and treatment of cancer in the area of the Board recommended that Clinics be established and that the various Hospitals be asked to co-operate for this purpose. "At the King Edward Hospital active assistance and hearty co-operation are offered to facilitate early diagnosis and treatment to persons residing in the district. The West Middlesex Hospital could be made available to a wider circle and would thus render a great service if too strict a line were not drawn as to the financial position of the patient and if the rule as to cases going in the first place through the Relieving Officer could be relaxed. I think, however, that the old prejudice against the Poor Law Institution, though why this should continue I cannot conceive, will militate against the utilisation of the West Middlesex Hospital to the greatest extent, and that the most must be made of the King Edward Hospital. "As the King Edward Hospital caters for the district of Greenford as well as Ealing these remarks on the facilities for diagnosis and treatment apply also to that area. With regard to Hanwell in some instances patients may be referred by their doctors to the King Edward Hospital, but the Hanwell Cottage Hospital Authorities are prepared to offer all the facilities for diagnosis and treatment to those residing in their district, the procedure being practically the same as at the King Edward Hospital. Patients from Greenford and Hanwell coming within the Poor Law will of necessity go to the West Middlesex Hospital in the same way as patients from Ealing. 25 "I am sending a circular letter to all medical men in the district seeking their assistance and co-operation in the education of the public and in the early diagnosis of the disease and informing them of the facilities for diagnosis and treatment offered at the King Edward Hospital and the West Middlesex Hospital. THOMAS ORR, Medical Officer of Health. 2nd February, 1925. "Town Hall, "Ealing, W.5. "14th February, 1925. "Dear Sir, "I am sending herewith a copy of a Report on Cancer which I have submitted to the Town Council, and at the same time I take the opportunity of soliciting your assistance and co-operation in quietly informing the public, without undue alarm, of the value of early diagnosis and treatment of Cancer. My view is that the public ought to be taught to call in a doctor whenever there is a lump or enlargement in any part of the body or where there is any abnormality or lowered condition of health. If advice is suitably given it would apply to other important diseases as well as cancer which call for early treatment. "As the early diagnosis of cancer is of vital importance in its treatment and as the medical practitioner frequently requires assistance in difficult cases I wish to draw your attention to the facilities which are offered, for those patients who are unable to afford the fee of a consultant, at the King Edward Memorial Hospital and at the West Middlesex Hospital where specialists can be consulted and where X-ray departments are available for diagnosis. "When a case is referred to the King Edward Hospital all that the medical attendant need do is to send his card or a short note with the patient. The West Middlesex Hospital deals with persons coming within the Poor Law and in such cases the patient is only dealt with through the intermediary of the Relieving Officer. It is hoped, however, that this procedure will be modified and that a medical attendant will be able to refer patients direct to the West Middlesex Hospital for diagnosis and treatmen tby the simple means of sending his card, 26 "In all probability the facilities offered at the King Edward Hospital will be more convenient to the doctor and patient, and I trust they will be fully taken advantage of in order to try to lessen the mortality and suffering from this disease. "I am asked by Dr. Thomson, Medical Officer of Health for Greenford, to say that the procedure with regard to patients from Greenford is the same as from those Ealing. "For persons residing in Hanwell facilities for diagnosis and treatment are also offered at the Hanwell Cottage Hospital, to which they may be referred by the patients' usual medical attendant in the same way as patients are referred to the King Edward Memorial Hospital. "Yours faithfully, "Signed THOMAS ORR, Medical Officer. Heart Disease.—Heart disease is a condition which compels attention by its high mortality. The figures are eloquent testimony of the need for concerted thought being brought to bear on the subject. By far the most important cause of heart disease is rheumatism which affects all ages, but which is a formidable disease in the young, leaving an indelible mark on most of those who are attacked in the way of heart affection.. The prevention of rheumatism, particularly in children, therefore, calls for immediate consideration. We are, unfortunately, not at present in a position to say with any measure of exactitude what are the factors which determine the disease, much research and enquiry being required to elucidate these, but we know there are certain predisposing causes such as dampness, especially if associated with cold, anaemia and perhaps septic conditions of the nose, mouth or other parts of the body. In fact, we might almost say with some approximation to the truth that any circumstance which lowers the health in susceptible persons will act as a predisposing cause of the disease. Moreover there is sufficient evidence that there are persons who are more susceptible than others, for frequently there is a history of more than one member of a family being affected with rheumatism. A 27 history of rheumatism in the father or mother should, therefore, cause special preventive measures to be taken with regard to the child. By devoting particular attention to the prevention of rheumatism at all ages we might hope to lower the great mortality from heart disease. table iv. Causes of Death, 1925. Cause of Death. Male Female Total Enteric Fever 1 — 1 Smallpox — — — Measles — — — Scarlet Fever — 1 1 Whooping Cough 2 1 3 Diphtheria 1 3 4 Influenza 12 12 24 Encephalitis Lethargica 2 — 2 Meningococcal Meningitis — - — Tuberculosis of Respiratory System 19 20 39 Other Tuberculous Diseases 6 7 13 Cancer, Malignant Disease 36 55 91 Rheumatic Fever 1 1 2 Diabetes 7 3 10 Cerebral Haemorrhage, Etc. 17 25 42 Heart Disease 44 58 102 Arterio-Sclerosis 13 9 22 Bronchitis 20 35 55 Pneumonia (all forms) 14 14 28 Other Respiratory Diseases 6 5 11 Ulcer of Stomach or Duodenum 5 1 6 Diarrhoea, etc. (Under 2 years) 1 2 3 Appendicitis and Typhlitis 2 4 6 Cirrhosis of Liver 2 2 4 Acute and Chronic Nephritis 4 8 12 Puerperal Sepsis — 2 2 Other Accidents and Diseases of Pregnancy and Parturition - 1 1 Congenital Debility and Malformation, Premature Birth 18 12 30 Suicide 2 3 5 Other Deaths from Violence 11 10 21 Other Defined Diseases 56 89 145 Causes ill-defined or unknown — — — Total 302 383 685 28 GENERAL PROVISION OF HEALTH SERVICES IN THE AREA. Hospitals Provided or Subsidised by the Local Authority. (1) Tuberculosis.—There are no hospitals for tuberculosis in the Borough. The Tuberculosis Scheme for the district is combined with that for other districts in the hands of the County Council, who provide hospital accommodation for cases of tuberculosis at Clare Hall and elsewhere. (2) Children.—The King Edward Memorial Hospital has a ward of 12 beds reserved for children. The Town Council may use six of these for badly thriving or wasting children who may require indoor treatment, and who may be referred by the Medical Officer at the Child Welfare Centre. (3) and (4) Maternity and Fever.—By an agreement in 1921 the Councils of the Borough of Ealing and the Urban District of Chiswick placed their respective Isolation Hospitals, which are in close proximity at South Ealing, in the hands of a newly constituted Committee, the Chiswick and Ealing Hospitals Committee, to manage the Chiswick Hospital as a Maternity Hospital for maternity cases and the Ealing Hospital as a Fever or Isolation Hospital to deal with cases of scarlet fever, diphtheria, enteric fever, and when there is accommodation, other infectious diseases, from both districts. The Maternity Hospital has accommodation for 20 beds and the Isolation Hospital for 120 beds. The arrangement has proved very satisfactory not only in providing a maternity hospital for both districts, but in enabling both institutions to be managed with great economy. (5) The Ealing Town Council has a separate Smallpox Hospital with 12 beds at Perivale, just over the northern boundary of the Borough. A reception-house for isolating persons who have been in immediate contact with cases of smallpox is situated at North Ealing on a site adjoining the Northern Sewage Works and about half a mile from the Smallpox Hospital. This consists of two wards which provide for two families or eight persons. 29 Ambulance Facilities. (a) For Infectious Cases.— The Chiswick and Ealing Hospitals Committee have a motor ambulance in which all cases of infectious disease are removed to their Isolation Hospital in South Ealing. (b) For Non- Infectious and Accident Cases.—The Council has two motor ambulances for the removal of general or accident cases to the local hospitals or nursing homes or to hospitals in London. One of these is a new ambulance purchased last year and the other is a war-time ambulance lent by the Middlesex Ambulance Committee. The latter is being replaced by a modern ambulance, similar to that already possessed by the Council. These ambulances also serve the demands of Hanwell and Greenford. Clinics and Treatment Centres. Name Address Provided by Maternity and Child 13, Mattock Lane, Ealing Borough Welfare Centre. Ealing. Council. Day Nursery Uxbridge Road, Hanwell Urban Hanwell. District Council. School Clinic. 13, Mattock Lane, Ealing Educa- Ealing. tion Committee. Tuberculosis Dispensary. Green Man Lane, Middlesex West Ealing. County Council. Treatment Centres for Certain Hospitals Middlesex Venereal Disease. in London. County Council. Professional Nursing in the Home. (a) General.—In 1920 the District Nursing Association was formed to provide nursing assistance for the poorer inhabitants of the district. A beginning was made by the employment of one whole-time nurse, later a second nurse was engaged to devote half her time to the work and the question of employing the second nurse for the whole of her time has recently been under consideration (b) For Infectious Diseases.—Provision is made for two of the health visitors, who are trained nurses, attending cases of ophthalmia neonatorum and infectious diseases, such as measles, whooping cough and poliomyelitis occurring in children under 5 years of age, 30 Midwives.—-There are 16 midwives (four of these are in the Maternity Hospital) in the district, all of whom are trained. They are supervised by the County Council. The Town Council, in its scheme of maternity welfare, does not employ any particular midwife to attend women who are in necessitous circumstances at their confinement, but the midwife nearest the woman's residence is engaged and paid by the Council. As the work of all the midwives in the district has been found to be of a high standard any one can be employed by the Local Authority with confidence. Legislation in Force. In the following list are noted all the Local Acts, Adoptive Acts, Byelaws, and Regulations in force in the Borough:— Adoptive Acts. Public Health Acts (Amendment) Act, 1890. 20th November, 1890. Infectious Disease (Prevention) Act, 1890. 18th December, 1890. Public Health Acts (Amendment) Act, 1907. 21st December, 1908. Notification of Births Act, 1907. 9th May, 1912. The Ealing Corporation Act, 1905, confers additional powers on the Council with respect to certain sanitary matters, the provision of dustbins, the drainage of houses by combined operation, the control of tuberculous milk, etc. Byelaws, with date of making, with respect to : (1) Prevention of nuisances arising from sewage, filth, etc , keeping of animals, and (2) Cleansing of earth closets, privies, ashpits and cesspools, October 15th, 1880. Common Lodging Horses, February 4th, 1881. Slaughter Houses, March 6th, 1884. (Added: Humane Slaughtering of Animals, 1922). New Streets and Buildings, 23rd July, 1925. Byelaws under Section 26 (1) of the Public Health Acts (Amendment) Act, 1890. June 20th, 1907. 31 Tents, Vans, Sheds, etc., under the Housing of the Working Classes Act, 1885. July 2nd, 1907. Prevention of Keeping Animals on any premises so as to be injurious to Health. July 15th, 1910. Regulations: Regulations under the Dairies, Cowsheds and Milkshops Order of 1885. October 6th, 1887. Communications between Drains and Sewers, Section 21, Public Health Act, 1875. October 8th, 1908. In view of the proposals for the extension of the boundaries of the Borough the adoption of Parts II, III, IV and V of the Public Health. Act, 1925, has been postponed. SANITARY CIRCUMSTANCES OF THE AREA. Water.—The Borough is supplied with water by the Metropolitan Water Board. Rivers and Streams.—The Brent, which forms the northern boundary separating Ealing from Wembley and Greenford, is the only stream to be considered under this heading. A few years ago it was grossly polluted by a neighbouring sewage works, but since these works have been reconstructed a great improvement has been effected. During the last two yeais there has not been a single complaint, a condition of affairs which is in great contrast to that which was previously experienced. Drainage and Sewerage.—Most of the drainage of the town is of modern construction. In recent years a large amount of reconstruction of drains has been carried out so that at the present time it is only a comparatively small number of the old houses which do not come up to good sanitary requirements. These, however, are being gradually dealt with, either in the course of the regular house-to-house survey or when the opportunity offers, when a complaint has been made by the occupier or a nuisance has been observed by the Inspectors. There is only a small area of the north-east corner of the Borough which is not connected with the main sewerage system. Only two houses and a factory are concerned. The former are drained to cesspools and the latter to separate privately-owned sewage works of an efficient nature. 32 Sewage disposal is very efficient. The Northern Sewage Works deal with about 240,000 gallons of sewage per day and the Southern Works about one-and-a-half million gallons per day. Treatment is by precipitation with sulphate of iron, followed by sedimentation and filtration of the effluent by intermittent downward filtration or over contact beds. At the Northern Works the effluent is passed through a "Humus" tank before being finally discharged into the Brent. The sludge is treated with lime and pressed into cake for which there is a demand as a manure for agricultural purposes. Any sludge-cake which may accumulate at the Southern Works is burned in the refuse destructor which adjoins. Closet Accommodation. Excepting a temporary building and two small cottages which are at a distance from a sewer the whole of the houses in the Borough are supplied with water closets. As a rule there is one water closet to each house, but in many instances houses have been sub-let so that more than one family may use the same convenience. Where, however, a house is permanently converted into flats separate accommodation for each family is required. Scavenging.—By the Ealing Corporation Act all premises must be supplied with a sanitary dustbin of a suitable size and with a proper cover. This requirement is rigidly enforced. Removal of household refuse is carried out weekly. A destructor comprising ten cells, which is situated at South Ealing, adjacent to the Sewage Works, receives and burns the refuse from the whole district. Sanitary Inspection of the Area.—The following is a summary of the work of the three Sanitary Inspectors during the year and of other action taken under the Public Health Acts, Byelaws, Etc. General. Number of Premises inspected on Complaint 309 Number of Nuisances observed by Inspectors 73 Number of Premises inspected in connection with Infectious Disease 273 Number of Premises visited by Periodical Inspection (Cowsheds, Dairies, Slaughterhouses, Workshops, Etc.) 602 Number of Houses inspected under House-to-House Survey 658 33 Food Inspections 6,375 Total number of Re-inspections 5,627 Other Inspections 536 Total number of Inspections and Re-Inspections 14,453 Number of Intimation Notices given 399 Number of other Letters written 209 Number of Statutory Notices served 127 Proceedings before Magistrates 1 Dairies, Cowsheds and Milkshops. Number of Cowsheds on Register 1 Number of Inspections made of Cowsheds 9 Contraventions of Regulations 1 Number of Retail Purveyors of Milk on Register 48 Number of Inspections of Retail Purveyors' Premises 189 Contraventions of Regulations 15 Proceedings before Magistrates - Slaughterhouses. Number of Registered or Licensed Slaughterhouses 5 Number of Inspections made 107 Contraventions of Regulations — Proceedings before Magistrates — Factories and Workshops. Registered Workshops 183 Factories 44 Number of Inspections of Factories 951 295 and Workshops and Workplaces 200 Number of Defects concerning which Notices were sent 7 Proceedings before Magistrates — Offensive Trades. Fried Fish Shops 11 Other Offensive Trades — Number of Inspections 211 Contraventions — 34 Disinfection. Rooms Disinfected by Spray:- (a) Ordinary Infectious Disease 385 (b) Tuberculosis 76 Rooms stripped and cleansed 97 Articles disinfected by steam at disinfector:— (a) Ordinary Infectious Disease 1,802 (b) Tuberculosis 179 Articles voluntarily destroyed 138 Particulars of the Sanitary Defects referred to in Notices Served and Letters Written. Water Closets repaired or supplied with water or otherwise improved 248 Drains cleared and cleansed 52 Defects in Drains repaired 82 Drains reconstructed 26 Dust-bins provided 67 Overcrowding remedied 2 Accumulations of refuse removed 56 Nuisance from fowls and other animals abated 7 Damp-proof courses inserted in walls 85 Ventilation under floors provided 29 Other forms of dampness remedied 48 Yards paved and repaired 55 Floors repaired 38 Roofs, Gutters and Rain-water Pipes repaired 324 New Soil and Ventilating Pipes provided 73 Sinks and Waste-pipes repaired or renewed 134 Draw Taps fixed to main supply 9 Dirty Walls and Ceilings stripped and cleansed 792 Other Defects or Nuisances remedied 378 35 FACTORIES, WORKSHOPS AND WORKPLACES. 1.—Inspection of Factories, Workshops and Workplaces. Including Inspections made by Sanitary Inspectors or Inspectors of Nuisances. Premises (1) Number of Inspections (2) Written Notices (3) Prosecutions (4) Factories (Including Factory Laundries) 95 — — Workshops (Including Workshop Laundries) 191 3 — Workplaces (Other than Outworkers' premises) 9 1 — Total 295 4 — 2.—Defects found in Factories, Workshops and Workplaces. Particulars (1) Number of Defects. Number of Prosecutions (5) Found (2) Remedied (3) 1 Referred to H.M. Inspector. (4) Nuisances under the Public Health Acts— Want of Cleanliness 47 47 - — Want of Ventilation — — — — Overcrowding — — - — Want of drainage of floors — — — — Other Nuisances 12 12 - — Sanitary accommo- dation insufficient 1 1 - — unsuitable or defective 2 2 - — not separate for sexes — — - — Offences under the Factory and Workshop Acts Illegal occupation of underground bakehouse (s 101) - - — — Other Offences 3 3 — — (Excluding offences relating to outwork and offences under the Sections mentioned in the Schedule to the Ministry of Health (Factories and Workshops Transfer of Powers) Order, 1921.) Total 65 65 — — 36 Outwork in Unwholesome Premises, Sec. 108. Nature of Work Instances Notices Served Prosecution Wearing Apparel Making, Etc. 2 2 — Others — — — Smoke Abatement.—Owing to the small number and the nature of the factories in the Borough there is seldom any ground for complaint as to smoke. Two complaints of nuisance from smoke were investigated during the year. One was with regard to a small factory which had just been opened and in which the early trials of stoking the boiler furnace were at fault and the other had reference to a temporary boiler which was being used while a new boiler was being installed. The emission of black smoke was only temporary and was soon remedied. Premises and Occupations which can be Controlled by Byelaws and Regulations.—There are no common-lodging houses in the Borough and no byelaws with respect to houses letin-lodgings have been made. The only offensive trade in Ealing is that of fish-frying which is carried on in eleven shops. Although visited on many occasions they were at all times found to be well managed. Public Baths.—Situated behind the Town Hall are the Public Baths provided by the Council. They consist of four swimming baths, one being reserved entirely for elementary school children, a series of slipper baths and radiant-heat baths. During the year the Council decided to install Bell's Pressure Filters for the purpose of continuously filtering the water in the swimming baths. In the summer months, when the baths are freely used, unless the water is changed frequently the baths become grossly polluted with suspended matter and particularly with micro-organisms, a condition which is to be condemned not only from the aesthetic but from the public health aspect. To empty out the water and refill is an expensive proceeding, to which recourse cannot be had often if the cost of maintenance is to be kept within reasonable limits. Continuous filtration, therefore, is recommended. By means of Bell's Filters the whole of the suspended matter is removed, and from 37 94 to 96 per cent. of the bacteria are also eliminated, thus affording a great measure of protection from infection. These filters have just recently been set in action and the results are so apparent to the naked eye that intending bathers will not now need to enquire on what days fresh water is put in, but will be encouraged to use the baths at any time, and oftener than they have done in the past. In accomplishing this good public health work the Baths Committee are to be heartily congratulated. Schools.—The sanitary condition of all the public elementary and private schools is investigated at least once a year by the Chief Sanitary Inspector. In two of the elementary schools defects in the sanitary arrangements were found and remedied. The reconstruction of St. Saviour's Junior School, which has very evident and serious sanitary defects has been decided upon by the Managers. In preventing the spread of infectious disease in schools the weekly returns sent by the head-teachers of absentees due to non-notifiable infectious disease are extremely valuable. By these returns early information of an outbreak is obtained so that appropriate steps for control can at once be taken. Visiting of the homes is carried out by the health visitors who give instruction to to the mothers regarding the prevention and spread of infection and the care of the patients. During the year certificates were given to the Education Committee that the fall in attendance below 60 per cent. was attributed to the prevalence of epidemic illness in three schools, two on account of influenza and the third on account of measles. Closure was not resorted to with regard to any school. HOUSING. The housing difficulties in Ealing are just as acute as in most towns. From 1916 to 1920 only 30 houses were built by private enterprise and 65 by the Council, and during the last five years, 1921 to 1925, 792 by private enterprise and 208 by the Town Council. Only the latter can be truly said to be houses for the working classes. And when one comes to consider the Council's recently built houses at rentals varying from 15/6 to 22/6 per week 38 it must be concluded that few can be occupied by the working classes unless they are helped to pay the rent by sub-letting. In practice this is what happens. The housing problem is therefore complicated by the two questions, first, that of providing a sufficient number of houses, and secondly, the inability of the ordinary working man to pay the rent demanded for a house which is in all respects sufficient for him and his family. While the builder cannot build houses to let at a reasonable rent to the working man every new house serves to relieve the pressure in the lower grade houses. During the year 1925, 241 houses were built by private enterprise and many more are contemplated. The remaining land, however, which is suitable for building sites is quickly being used up and the natural result will be that building sites will be sought in Greenford, which it is expected will be included within the Borough next October. During the year the erection by the Council of 250 houses was begun on the 24 acres of land purchased for the purpose in Pope's Lane. None has yet been completed. There are very few houses that are in such a condition as to demand steps for closure under the Housing Acts. Action has been deferred on account of the difficulty of providing accommodation for those families displaced. When, however, the pressure is relieved by the completion of some of the houses being erected by the Council, representations will be made. Overcrowding.—It is very difficult to gauge the extent of the overcrowding and to express it in exact figures but every day attention is being drawn to cases of gross overcrowding which are difficult to remedy. The worst cases are reported to the Housing Committee with a view to their special consideration when vacancies in the Council's houses are being allocated, but in many cases the only remedy that can be recommended is the re-arrangement of the rooms by which a more reasonable allotment of sleeping accommodation can be given to the different families inhabiting the house. Fitness of Houses.—The general standard of housing in the district is good. There are no slums, as such are generally understood, although there are three small areas with houses of a low 39 standard, many of which are made slum-like by sub-letting on the part of the tenants, the consequence of which is bad overcrowding often accompanied by want of cleanliness or bad treatment of the houses. A striking result of misuse by tenants is found in two roads in South Ealing where many of the houses which are of fairly modern construction and which, though they look fairly well from the outside, are in a bad condition internally. These houses are constantly receiving inspectorial visits by the Sanitary Inspector and the owners are constantly carrying out decorative and other repairs with but little lasting effect on account of the ill-use or neglect to which they are exposed. On the whole the owners and the house agents meet the demands of the Inspectors in a very reasonable spirit, with the result that very few prosecutions are necessary to effect the large amount of repairs which are done each year. A large amount of work has been done by the Inspectors in successive years in having houses rendered in every respect reasonably fit for habitation. In the Table which follows it will be noted that 584 houses were surveyed, and rendered reasonably fit when found necessary, during 1925 and that as many as 1,325 houses were inspected for housing defects. No action has been taken with respect to unfit houses under the Housing Acts, the procedure under the Public Health Acts proving much more simple and satisfactory in dealing with the defects encountered. Unhealthy Areas.-—No complaints have been received and no representations have been made with respect to unhealthy areas. Byei.aws Relating to Houses.—The old Byelaws with respect to new streets and buildings were replaced by new ones which were adopted in 1925, and which were agreed upon by various municipal councils in the western suburbs in order to secure unifoimity. 40 HOUSING STATISTICS FOR THE YEAR 1925. A.—Number of New Houses Erected during the Year. (а) Total 241 (b) As part of a municipal housing scheme — B.—1. Unfit Dwelling Houses. Inspection. (1) Total number of dwelling houses inspected for housing defects (under Public Health or Housing Acts) 1,325 (2) Number of dwelling houses which were inspected and recorded under the Housing (Inspection of District) Regulations, 1910 584 (3) Number of dwelling houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation — (4) Number of dwelling houses (exclusive of those referred to under the preceding sub-heading) found not to be in all respects reasonably fit for human habitation 467 2. Remedy of Defects without Service of Formal Notices. Number of defective dwelling houses rendered fit in consequence of informal action by the Local Authority or their Officers 432 3. Action under Statutory Powers. (a) Proceedings under Section 28 of the Housing, Town Planning, etc., Act, 1919:— (1) Number of dwelling houses in respect of which notices were served requiring repairs — (2) Number of dwelling houses which were rendered fit:— (a) By Owners — (b) By Local Authority in default of Owners — (3) Number of dwelling houses in respect of which Closing Orders became operative in pursuance of declarations by Owners of intention to close — 41 (b) Proceedings under Public Health Acts:— (1) Number of dwelling houses in respect of which Notices were served requiring defects to be remedied 127 (2) Number of dwelling houses in which defects were remedied:— (a) By Owners or Occupiers 104 (b) By Local Authority in default of Owners — (c) Proceedings under Section 17 and 18 of the Housing, Town Planning, etc., Act, 1909:— (1) Number of representations made with a view to the making of Closing Orders— (2) Number of dwelling houses in respect of which Closing Orders were made (3) Number of dwelling houses in respect of which Closing Orders were determined, the dwelling houses having been rendered fit— (4) Number of dwelling houses in respect of which Demolition Orders were made— (5) Number of dwelling houses demolished in pursuance of Demolition Orders— INSPECTION AND SUPERVISION OF FOOD. (a) Milk Supply.—The whole of the milk supply of Ealing comes from outside, there being no milk producers within the district. One cowshed was abolished during the year and the building was converted into a large milk distributing depot. There were 49 retail purveyors of milk on the Register, compared with 46 in the previous year. Nineteen of these registrations were in respect of premises owned by one company and used only as distributing places, the milk being bottled at a central depot within the London area ; four were in respect of shops in the management of another company which deals only with bottled sterilised milk prepared also in London. The three new registrations were concerned with new premises, one being simply a distributing place for milk in bottles and the other two ordinary retail premises. All were put into a thoroughly 42 satisfactory condition before the applicants' names were placed on the Register. Two premises changed hands during the year and, as their condition was in every way satisfactory, the new occupiers were placed on the Register. One of the retail purveyors of milk mentioned above is also a wholesaler. During the last five years a great improvement has taken place in the character of the places where milk is sold and also in the manner in which it is handled. This change has taken place as a result of the acquisition of some of the old premises by a large company, owing to trade competition and also because of the pressure brought to bear on those handling milk by the public health department. For the same reasons bottling of milk in the district has become the rule and only a small quantity of milk is retailed from open cans. Further, it may be said that at least 80 per cent. of the milk supplied in the district has been pasteurised by the "positive holder" method, to which reference will be made later, and bottled. A proportion of the remaining 20 per cent. is pasteurised by the "flash" method, particularly in the warmer months of the year. The Milk and Dairies (Consolidation) Act which came into operation on the 1st September, 1925, together with the Tuberculosis Order which had been suspended during the war, should, when Orders have been made under Section 1 of the Act, do much to improve our general milk supply, particularly its quality as it leaves the cowshed. If these Acts and Orders are administered in a thorough manner, especially by the County Councils, whose duty it is to supervise production of milk in the country districts, a marked improvement should be effected in a few years. The natural result of this improvement is sure to be greater confidence of the public and an increased consumption of milk. It will therefore be greatly to the advantage of the farmer if he recognises his responsibility and carries out the improvements which are so much needed on his part. No action has been taken with regard to tuberculous milk, but proposals are being put forward for the regular examination of milk for the presence of the bacillus of tuberculosis so as to stimulate and assist County Councils in carrying out their duties under the Milk and Dairies (Consolidation) Act, 43 Under the Milk (Special Designations) Order, 1923, seven licenses were granted for the sale of "Certified" milk (five in respect of separate premises in the same ownership), seven were granted for "Grade A (Tuberculin Tested)" milk (five in respect of premises in the same ownership), and 18 were granted for "Pasteurised" milk, all of which were in respect of premises in the same ownership. In only one of the above premises mentioned is the special milk bottled on the premises and this is Grade A (Tuberculin Tested) milk. So widespread is the want of knowledge regarding the various grades of milk that it is desirable to give some description of them for the guidance of the public. "Certified" milk stands first in quality. It is produced from cows which have been shown by the tuberculin test to be free from tuberculosis, is handled with scrupulous care, cooled and bottled at the farm. "Grade A (Tuberculin Tested)" milk is also obtained from tuberculin tested stock, is handled with special care and is cooled before leaving the farm where it may or may not be bottled. "Grade A" milk is produced with the same care as the previous milk, but the cows are not tuberculin tested although they must be inspected by a veterinary surgeon every three months. These three grades are all raw milk, that is, milk which has not been treated by heat. The first must not contain more than 30,000 bacteria per cubic centimetre and the other two, more than 200,000 bacteria per cubic centimetre before delivery to the consumer. Certified milk offers the greatest security to the consumer from infection from tuberculosis and extraneous infection, but "Grade A (Tuberculin Tested) milk" also offers the same security against tuberculosis and a very large measure of protection from outside infection. Certified milk costs by retail double that of ordinary milk, whereas Grade A (Tuberculin Tested) costs up to 50 per cent, more than ordinary milk. Grade A milk does not give the same security from tuberculosis, for a veterinary inspection is not sufficient to tell whether a cow is or is not suffering from tuberculosis unless the disease is advanced and by that time it may have done a great deal of damage in infecting consumers of its milk. Grade A (Tuberculin Tested) milk is very good value for. the extra price and is highly to be commended. It appears, however, that some alteration of the designation is required since it is often confused 44 with the inferior article, Grade A. Perhaps it would not be fair to rename these designated milks "A", "B" and "C," for then "B" and "C" might be deemed by the public to be inferior to ordinary milk, but it might be desirable to call "Grade A (Tuberculin Tested)" simply "Grade Al," an appellation which we have recently been taught to consider of special significance in relation to other matters. The Grades would then be "Certified," "Grade A1" and "Grade A." The last grade is really the first step to the higher grade to which all producers should aspire. "Pasteurised" milk is milk which has been heated to from 145 deg. to 150 deg. F. and kept at that temperature for half an hour. This milk must be cooled and must not contain more than 100,000 bacteria per cubic centimetre. It has been conclusively shown that pasteurisation in this way (the "positive holder" method) destroys tubercle bacilli and other disease-producing organisms which may gain access to milk. As such it may be considered a safe milk and is to be recommended in preference to the ordinary milk or milk pasteurised by heating for only a few seconds ("flash-process") which may reduce the number of bacteria present and lessen the liability to souring, but which cannot be depended upon to kill the bacillus of tuberculosis. Pasteurised milk, when carried out by the first and legally approved method, has the small disadvantage that the Vitamin C (anti-scurvy) is almost entirely destroyed, but this can readily be supplied, particularly in infant feeding, by giving a little fruit juice. One note of warning, however, must be uttered. It must not be thought that pasteurisation is the remedy for the milk question. It is really a confession of failure to produce at the present moment a uniformly safe milk supply. Our object should be to produce a tubercle-free milk with such care and attention to cleanliness that no treatment by heat is required. In other words our aim should be Grade A (Tuberculin Tested) or, if it ought to be called a better name, "Grade Al," milk for the whole country. There was no refusal or revocation of registration of retailers or of licenses for graded milk. 45 During the year the following bacteriological results of samples of specially designated milk were obtained:— Total Sample Bacteria B. Coli. Certified 2,833 Not found in 1 c.c. Certified 5,166 „ Certified 1,370 „ Grade A (T.T.) 2,853 " Grade A (T.T.) 11,800 " Pasteurised 4,153 ,, Pasteurised 18,366 Not in 1 c.c. Present in c.c. From these figures it will be appreciated how much the samples come within the standards mentioned above. (b) Meat.—1. The Public Health (Meat) Regulations, 1924, made little alteration in the procedure with regard to meat inspection in Ealing, for it has been the practice for some years for the butchers to notify when they intended slaughtering so that the Inspector could inspect the meat. No system of marking has been adopted because the amount of killing done in the district is very small indeed and what is killed is simply for local consumption. Most of the meat sold in the Borough comes from the Smithfield Market, where it has already undergone inspection. 2. There has been a general attempt on the part of the butchers and provision dealers to carry out faithfully the requirements of the Regulations as regards the protection of meat in their shops. Conferences with both groups of traders were held, at which the Regulations were discussed and at which it was stated that they all welcomed the Regulations. All the shops have been provided with windows and there appears, with but few exceptions, to be a concerted effort to carry into practice the full intention of the Regulations. The persons included in the few exceptions have received a warning and if there is undue exposure of the meat, action will certainly be taken. There are no stalls or vehicles on which meat is sold in this district. 46 3. There is no public slaughterhouse but there are five registered slaughterhouses in private ownership. There has been no alteration in the number 01 ownership of these from 1920 to 1925. As has already been stated, very little slaughtering is done in the private slaughterhouses. In the twelve months, only one beast, seven pigs and one sheep were killed and dressed. All were stunned by means of a humane implement, that adopted latterly being the Cash Captive-bolt Pistol which has been kindly lent by the Royal Society for the Prevention of Cruelty to Animals. (c) Other Foods.—Bakehouses and cooked meat shops have been inspected regularly. The exclusion of the latter from the Public Health (Meat) Regulations is disconcerting. The premises can be dealt with under the provisions of the Ealing Corporation Act, similar provisions to which are now in the Public Health Act, 1925, but surely it is important to prevent the contamination of cooked meat from dust and flies, in fact much more important than the protection of raw meat which in the process of cooking may have injurious contamination destroyed. It is to be hoped that the Meat Regulations will be made to apply to all classes of cooked meat and enable health officers to be consistent in their efforts to protect the public. The following are the amounts of unsound foodstuffs which were found and were voluntarily surrendered for destruction:— Food. Quantity Beef 131 lb. Fish 450 lb. Periwinkles 2 bushels Fruit: Oranges 288 Bananas 168 Vegetables : Cauliflowers 250 Handling of Food.—Attention has very properly been recently drawn to the question of the handling of all kinds of food and a Joint Committee composed of representatives of the Royal Sanitary Institute and the Society of Medical Officers of Health presented a report on the subject to the Ministry of Health and made suggestions with regard to legislation on the matter. This report, which gives a valuable summary of the question, has been published by the 47 Royal Sanitary Institute and is worthy of the attention of the general public. There is no need to enter into a discussion of the defects in the handling of all kinds of food which are therein indicated but it may be advisable to point out that the public, apart from legislation, could effect an enormous improvement. A purchaser can by verbal protest, and accompanied by a refusal to purchase articles which are improperly handled or are exposed to contamination, impress upon the trader the need for care in handling and for the protection of all articles of food. For example, if there was an insistent demand for paper-wrapped bread, it would be supplied generally ; if the protection of provisions, confectionery, sweets and other articles of food were consistently demanded by the public it would be forthcoming without legislation ; the exposure of fruit, sweets, fish, etc., to dust and flies at open windows or in open barrows or stalls would cease if the public looked askance at the improper exposure of such articles. The public should make up their minds to deal with traders who consider the interests of the public by exercising care and cleanliness in the handling and by preventing the exposure to contamination of all articles which are used as human food. 48 PREVALENCE OF, AND CONTROL OVER, INFECTIOUS DISEASES. In Table V are indicated the numbers of the various infectious diseases notified during the year compared with the previous nine years:— TABIE V. Disease 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 Diphtheria 37 66 36 46 56 186 282 56 61 40 Scarlet Fever 146 91 61 201 171 665 487 142 123 107 Enteric Fever (including Paratyphoid) 5 3 6 5 6 8 3 5 9 5 Puerperal Fever 1 — 2 3 5 9 3 9 3 6 Pneumonia : Primary — - — 30 38 21 33 32 47 57 Influenzal — - — 33 27 17 22 7 27 22 Acute Poliomyelitis — 2 1 — — 1 — — 3 — Cerebro-Spinal Fever 2 1 — 3 4 1 — 1 —. — Malaria — - — 40 27 3 4 2 — 2 Dysentery — - — 5 2 1 1 — — — Erysipelas 19 33 24 22 30 27 22 17 25 17 Encephalitis Lethargica — - — 3 1 1 3 1 6 4 Tuberculosis : (a) Pulmonary 86 92 110 83 63 80 69 92 74 90 (b) Non-Pulmonary 15 17 22 25 17 23 16 26 31 25 Ophthalmia Neonatorum 8 4 3 4 8 13 10 3 3 6 Total 319 309 265 503 455 1036 955 393 412 381 Diphtheria.—It will be seen that only forty cases of diphtheria occurred during the year. These were distributed throughout the year as indicated in Table VI. The number notified is the lowest since 1918, in which year there were 36 cases. There were four deaths from the disease giving a death-rate of 0.06 per 1,000 of population and a mortality rate of 10 per cent. of cases. This death-rate from diphtheria compares favourably with those for England and Wales, the Great Towns and for London, which were respectively 0.07, 0.09 and 0.11 per 1,000 of population. The Bacteriological Laboratory is of great assistance in enabling medical practitioners to have confirmatory evidence of the nature of the disease. Too much stress, however, should not be placed by the doctors on a negative result. If a case shows membrane of any kind on the fauces it should be treated as diphtheria and the specific anti-toxin given, for negative bacteriological results are sometimes 49 obtained even from typical cases of diphtheria, owing either to the swab not being taken properly or because only a few diphtheria organisms have been taken on the swab with many others, which latter grow luxuriantly on the bacteriological medium and so greatly overwhelm in numbers the specific organisms which cannot be seen on microscopic examination. Swabbing is especially valuable in detecting "carriers" or "missed" cases where there is no membrane to be seen on the throat or where the nose is involved. As diphtheria may, in some cases, progress so rapidly that the patient is soon overwhelmed with the diphtheria toxin it is imperative that not only should the disease be recognised early but that anti-toxin should be given at the earliest possible stage of the disease. To facilitate the early administration of the specific anti-toxin supplies are available at the Town Hall where they can be obtained by medical practitioners at any time of the day. In necessitous cases the anti-toxin is supplied free by the Council. Fatal results sometimes occur because the parents have delayed calling in a doctor in the early stages and have only sent for him when there is little hope. Unfortunately patients in the early stages often do not show the usual symptoms of acute illness, the temperature may not be high and the throat may not be very sore and sometimes it is only after two or three, or even four days' illness that the doctor is sent for; then the submaxillary glands are much enlarged and serious complications are likely to follow. Every opportunity, therefore, is taken to impress upon the parents the urgent necessity of calling in a doctor in all cases of sore throat. During the year 52,000 units of anti-toxin were supplied free of charge for administration by medical practitioners in necessitous cases. Scarlet Fever.—The number of cases of scarlet fever was also the lowest since 1918, 107 cases having been notified. The distribution of the cases in the months of the year is indicated in Table VI. It will be seen that the months in which most cases occurred were February, 15; April, 12; August, 10; November, 11; and December, 18. The cases, even in these particular months, were widely scattered throughout the district with little discernible relationship between them. There was only one death from scarlet 50 fever, giving a scarlet fever death-rate of 0.01 per 1,000 of population and a mortality rate of 0.9 per hundred cases. The scarlet fever death-rate compares favourably with that for England and Wales, the Great Towns and London, which were 0.03, 0.03 and 0.02 respectively. In order, as far as possible, to prevent the occurrence of "return" cases the Health Visitors visit all the cases after leaving the Isolation Hospital within 14 days to determine their progress and to discover if any nasal or ear discharge arises in the meantime. If such occur further isolation at home is advised and if the child is a school child exclusion for a longer period is recommended. During the year the Health Visitors made 85 first and 8 subsequent visits to cases discharged from the Hospital. TABLE VI. Scarlet Fever. Diphtheria. January 7 6 February 5 15 March 3 7 April 4 12 May 2 8 June 4 3 July — 5 August 2 10 September 2 8 October — 4 November 3 11 December 8 18 Total 40 107 51 Prevention of Diphtheria and Scarlet Fever. Diphtheria in spite of our knowledge of its causation and in spite of the specific treatment by means of anti-toxin still remains a baffling disease to control and at the same time an anxious disease to treat because of its high mortality. No doubt the death-rate from diphtheria is now one-third that of 50 years ago, chiefly due to the use of anti-toxin, but the disease is still prevalent, and there has been little decline in its prevalence and mortality in the last ten years. It is chiefly on account of its high mortality that our anxiety for its control arises. Scarlet fever on the other hand continues to be prevalent but fortunately the mortality has decreased and continues very low. In epidemic times, however, so great is the dislocation of social and commercial intercourse and so great is the expense of isolating actual cases that any suggestions for the control of the disease should be considered in a thorough and broad minded manner. As bacteriological swabbing and anti-toxin treatment have failed in quelling diphtheria investigators have cast about for some other means of control. Schick put forward in 1911 the test which has now acquired his name and by means of which the susceptibility of individuals to the disease can be determined. This consists in the injection into the skin of a small amount of diphtheria toxin. If the person is susceptible to the disease, in other words if the person does not possess sufficient immunity, certain appearances become evident round the point of injection within a short space of time. This test was taken up by Park and Zingher in New York and further developed and carefully applied to a large number of persons, chiefly children, the result being that there have been many definite observations made along the lines of Park and Zingher in many parts of the world. Reaction.—If the blood of the person injected contains insufficient anti-toxin, the toxin introduced is insufficiently neutralised and therefore causes reaction in the tissues. 52 Reaction appears after 12 to 36 hours and takes the form of swelling and redness at the site of injection. The reaction is clearly visible at the end of the second day becoming progressively intense and attaining its maximum after 3 to 5 days. It then disappears slowly leaving behind a brown patch, which desquamates in fine flakes and does not finally disappear until after three to six weeks. The zone of reaction is generally very small, from 1 to 2 centimetres in diameter but is rarely painful. The person who does not possess any anti-toxin in his blood will show an intense reaction, the intensity being inversely proportional to the quantity of anti-toxin present. A person possessing sufficient anti-toxin to neutralise the toxin injected does not show any local reaction at the site of injection. By means of this Schick test, which has been proved to be thoroughly satisfactory in its application, susceptibles can easily be determined and proper steps taken in the first place to prevent their exposure to infection and secondly to render them immune to diphtheria. Interesting observations have been made, particularly in New York and more recently in this councry, which have shown the susceptibility of persons at various ages. Somewhat similar results have been obtained in this country, although the actual percentages vary, as Dr. Robertson of Edinburgh has pointed out, according to the social status of the children. It has been found by Park in New York that the susceptibility to diphtheria is present in about the following proportions:— Under 3 months 15% 3 to 6 months 30% 6 months to 1 year 60% 1 to 2 years 70% 2 to 3 years 60% 3 to 5 years 40% 5 to 10 years 30% 10 to 20 years 20% 20 years and upwards 15% 53 The reason of this is that social status determines the exposure to the virus of the disease. It is very interesting to note that a large percentage of cases who have previously suffered from diphtheria give positive Schick reactions. The anti-toxin administered apparently prevents or at least does not encourage the acquisition of a lasting immunity. Artificial Active Immunisation.—When it has been determined that the person tested is susceptible, steps can be taken to induce an artificial active immunity. The term "active" is used to contrast the process with artificial "passive" immunity which is induced by the injection of the specific anti-toxin. Passive immunity lasts but a short time, 3 to 4 weeks, whereas the active immunity induced by artificial means lasts more or less throughout life. Park of New York and his collaborators have experimented since 1913 with an anti-toxin mixture of the diphtheria bacillus. He found that a suitable amount of diphtheria toxin neutralised to a certain extent with anti-toxin will induce in susceptible persons an active immunity of a lasting character. A standard toxin has been evolved as a result of careful and exact experiments. The dose of this mixture is injected into the person at a convenient site under the skin, usually of the arm. Three injections are given at intervals of 8 to 15 days. As a result of the injection an inflammatory reaction occurs, characterised by a slight swelling, redness and slight pain at the site of injection. All these symptoms, however, disappear rapidly and in only a few rare individuals do general symptoms of fever and shivering occur. Children tolerate an anti-toxin mixture better than adults. A certain number of accidents have been recorded after an injection of the toxin mixtures in America but these, it has been pointed out, have been due to the use of products of poor quality produced by uncontrolled firms. No untoward results have occurred in this country. 54 After many observations it has been generally concluded that anti-diphtheria immunisation is harmless. The immunity develops slowly bat is of a more or less permanent character. This can be definitely demonstrated by means of the Schick test after three months. The maximum immunity is not obtained until after the expiration of at least six months after the three injections. Zingher found that after toxin-anti-toxin injections 30% gave a negative Schick reaction after 2 months, 51% after 2½ months and 87% after five months. The protection cannot always be said to be absolute in all cases but it can be said to be as complete as any form of specific protection such as vaccination against smallpox or inoculation against typhoid. It can be said that from 90 to 95 per cent. receive complete protection. If however an immunised subject happens to be attacked with diphtheria the condition is quite a mild one of a transient nature. Zingher and Schroder have examined 106 children injected 3 to 6½ years previously, subjecting them year after year to the Schick test. All the children concerned remained negative to the test showing the immunity acquired to be more or less permanent. The incidence of diphtheria in New York is greater than in any town in this country, which possibly accounts for the active steps taken in regard to its control, and very large numbers of school children have been injected and kept under observation. The following figures supplied from that source are therefore interesting:— No. of Cases of Diphtheria 57,000 school children, negative Schick reaction 5 33,000 school children, positive Schick reaction but immunised 9 90,000 school children, negative Schick reaction or immunised 14 90,000 school children used as controls 56 55 It has been recommended that, as children under 5 years show by the Schick test a large percentage of susceptibles, there is no need to apply the Schick test and artificial immunisation should be carried out at once. Zingher, who has done more work in Schick testing and immunisation than any other person, recommends as follows:— 1. Infants under 6 months should not be immunised. 2. Children 6 months to 5 years should be immunised without the Schick testing. 3. Children of 5 years entering school should be immunised without the Schick test. 4. Older children up to 15 years should be immunised only if Schick test is positive. 5. Over 15 years, same procedure. Under 5 years of age half the deaths occur from diphtheria and attention should therefore be concentrated on that group. If the Schick test can be dispensed with in regard to them the procedure of immunisation is greatly simplified. The procedure would on the whole be greatly simplified and would perhaps meet with more ready acceptance on the part of the parents if the protective injections could be reduced from three to one, and if the severe reactions occasionally experienced after them could be mitigated. Improvement in this latter respect has been provided by the introduction of a modified toxin known as "toxoid." It is said that by the use of toxoid reactions are almost completely abolished. General Application of Schick Testing and Artificial Immunization.—The general public may be against the general adoption of immunization in the same way as with vaccination against smallpox but the protection should be available for those who desire it. Immunization is particularly applicable to small towns or isolated communities where diphtheria is epidemic and where other measures have failed to effect improvement. It can also be applied to large residential schools or institutions which are liable to 56 breaks of diphtheria. The protection is particularly desirable in the administrative staffs of our isolation hospital. The nurses at the Chiswick and Pealing Isolation Hospital are protected in this way. Parents may, when they know of the procedure, very laudably wish their children protected, particularly when they leave home for a boarding school or when alarm is caused by the presence of diphtheria in the neighbourhood. In these circumstances the family medical attendant should be prepared to carry out the Schick test or at least to perform artificial immunization. Scarlet Fever.—As to scarlet fever, experiments have, since the discovery of the causal organism in 1923 by Drs. George and Gladys Dick, rapidly followed on similar lines to those regarding diphtheria. Previous to that date it had been known that the blood serum of a scarlet fever convalescent would cause, when injected into the skin, blanching of the rash, round about the site of injection, in a patient in the acute stage of the disease. This test known as the SchulzCharlton test was shown to be specific and to be a valuable means of diagnosis in doubtful cases of scarlatiniform rash. After the discovery of the streptococcus of scarlet fever by Dr. and Mrs. Dick, who successfully produced scarlet fever in human volunteers by infecting the nasopharynx with a culture, steps were taken to produce a test similar to the Schick test in order to discover susceptibles and non-susceptibles to scarlet fever. This test, known as the Dick test, has been shown, first by Zingher in New York and afterwards by others in America and in this country to be almost as satisfactory for its purpose as the Schick test in diphtheria. The Dick Test.—The Dick test consists in the injection into the skin of a small quantity of the diluted toxin. A positive reaction indicates that the individual is presumably susceptible to scarlet fever while a negative reaction yields evidence that the individual is immune to the disease. A positive reaction begins to appear within a few hours, usually four to six after inoculation and reaches its maximal development in about 24 hours. There is a local area of redness varying in size and in intensity of colour, with usually clearly defined edges. At the expiration of 48 hours from the time of injection in most cases the reaction has completely disappeared or has faded considerably. 57 It has been found that scarlet fever convalescents give a negative reaction and that when the test is applied to large numbers of persons about 41.6 give positive reactions. Zingher found that in testing 4,570 normal persons of all ages the maximum number of positive reactions was found in infancy and decreased with advancing age as with the Schick test. Zingher believes that a strongly positive Dick test in a case diagnosed as scarlet fever of several days duration casts considerable doubt on the diagnosis. In the first few days of an attack of Scarlet fever the reaction is positive but later becomes negative. Okell and Parish found that of those with a history of scarlet fever 65% gave a Dick positive reaction, and recent convalescents 18%. Kerr, McCartney and McGarrity got 51.5% positives in 442 persons not suffering from scarlet fever and 79% negatives in scarlet fever patients on the 40th day of the illness. Immunization.—It has been found that the injection of the toxin into horses and sheep produces an anti-toxin which has curative effects on scarlet fever patients. This anti-toxin serum gives the Schulz-Charlton reaction in cases of scarlet fever. Further, the Dicks have tried to immunize a large number of susceptibles by injecting small definite doses of toxin on three occasions at 5 day intervals with apparently successful results. The whole question of the standardisation of the test and of specific active immunization is still being followed up by numerous experimenters in America, in this country and elsewhere so that before many years pass we shall have the Dick test so perfected as to be as trustworthy as the Schick test and that we shall be provided with a satisfactory means of immunizing susceptibles against scarlet fever as against diphtheria. In America the Dick test is being applied with the same enthusiasm as the Schick test, so that we can expect many reports of progress in the early future, 58 Measles.—Researches have recently been conducted along the same lines with regard to measles, the specific causal organism having been reported to have been discovered and a skin test evolved. Progress has also been made in treating cases of measles, markedly successful results having been obtained from the injection of blood serum from convalescent patients into others in the acute stage of the disease. The whole question of measles is still in the experimental stage and conclusions must be reserved until further evidence has been obtained. One may, however, express the hope that further experiments or observations with regard to these three diseases may show the practicability of one injection for the protection of children from all three. With the progress already made in recent years this does not seem too much to hope for. Such a protective treatment for all children would be of inestimable value to the community. 59 * (l)Drayton Ward (2) Castlebar Ward (3) Mount Park (4) Lanunas (5) Manor (6) Grange. table vii. Cases of Infectious Disease notified during the year 1925. Disease. Ages of Cases Notified. Totals. Total Cases Notified in each Ward Total cases removed to Hospital Under One Year. 1 to 2 2 to 3 3 to 4 4 to 5 5 to 10 10 to 15 15 to 20 20 to 35 35 to 45 45 to 65 65 and upwards 1* 2* 3* 4* 5* 6* Diphtheria 1 4 4 2 15 8 — 5 — 1 — 40 7 3 5 6 6 13 33 Scarlet Fever 1 4 4 8 7 35 20 10 14 2 1 1 107 11 13 14 23 27 19 81 Enteric Fever (including Paratyphoid) — — — — — 1 — — 2 — 1 1 5 _ 2 1 1 1 — — Puerperal Fever — — — — — — — — 2 4 — — 6 — — 1 1 2 2 — Pneumonia : Primary 5 6 1 3 1 7 4 3 6 5 10 6 57 3 4 3 13 23 11 — Influenzal — — — 1 — 1 — 3 5 2 4 6 22 1 6 4 4 6 1 — Acute Poliomyelitis — — — — — - — - - — — — — — — — — — — - Cerebro-Spinal Fever — — — — — — — — — — — — — — — — — — Malaria — — — — — — — — 1 1 - — 2 1 — - - — 1 — Dysentery — — — — — 1 — — — — — — — — — — — — — — Erysipelas — — — — — — — 2 6 7 1 17 3 2 2 4 2 4 — Encephalitis Lethargica 1 — — — — — — — 1 — 2 — 4 — 2 1 — 1 — — Tuberculosis : (a) Pulmonary Male — — — — — 1 — 5 20 8 10 — 44 9 4 3 9 10 9 — Female — — — — — 2 1 5 18 16 4 — 46 6 4 3 15 9 9 — (b) Non-Pulmonary Male — — 1 1 — 2 2 2 3 2 1 — 14 2 2 3 1 1 5 — Female — — — — — 2 4 — 5 — — — 11 1 1 1 2 2 4 — Ophthalmia Neonatorum 6 — — — — — — — — — — — 6 1 — 1 — 3 1 — Total 14 10 10 17 10 67 39 28 84 46 41 15 381 45 43 42 79 93 79 TABLE VIII. AGES AT DEATH FROM NOTIFIABLE INFECTIOUS DISEASES. Disease. Under One Year 1 to 2 2 to 3 3 to 4 4 to 5 5 to 10 10 to 15 15 to 20 20 to 35 35 to 45 45 to 65 65 and upwards Totals Diphtheria 1 1 1 1 A Scarlet Fever — - — 1 — — — — — __ MM 1 Enteric Fever (including Paratyphoid) _ 1 1 Puerperal Sepsis — — _ —. _ _ 2 2 Pneumonia : Primary 5 3 __ 2 6 11 27 Influenzal 1 1 Acute Poliomyelitis i Cerebro-Spinal Fever . Malaria Dysentery Erysipelas . Encephalitis I/ethargica - _ _ 1 1 2 Tuberculosis : (a) Pulmonary Male —. — — __. 4 5 4 6 19 Female — — — 3 8 5 4 20 (b) Non-Pulmonary Male — — 1 mmm 1 1 2 1 6 Female — 1 1 3 1 7 Ophthalmia Neonatorum — - — — — — — — Totals 5 3 2 2 1 2 2 10 22 10 19 12 90 I 0 1 61 Tuberculosis.—In Table IX are indicated the new cases of pulmonary and non-pulmonary tuberculosis notified in the year and the number of deaths in the various age-groups. There were 39 deaths from pulmonary and 13 deaths from non-pulmonary tuberculosis, which give death-rates of 0.57 and 0.19 respectively, or a total tuberculosis death-rate of 0.76 per 1,000 of population. In three instances the first information of the case of tuberculosis has been on the death of the patient, either through the medical attendant notifying or in the weekly death returns from the Registrar-General. When this has occurred the medical attendant has always been communicated with to avoid repetition of the omission to notify. No action has been called for under either the Public Health (Prevention of Tuberculosis) Regulations, 1925, or Section 62 of the Public Health Act, 1925. After the notification of a case of tuberculosis is received, a visit is made by the Sanitary Inspector to ascertain the history and mode of life of the patient, his occupation and sleeping accommodation, and to investigate the sanitary condition of the house. When deemed desirable the Tuberculosis Officer is communicated with— particularly if it is thought, on account of the home circumstances, that Hospital or Sanatorium treatment is desirable. Sanitary defects are attended to in the usual manner by the service of notices to remedy on the owner. The Tuberculosis Officer has very kindly supplied the followi information with respect to cases of tuberculosis from Ealing :— Number of persons examined for the first time by the Tuberculosis Officer:— (a) Tuberculosis of Lungs 39 (b) Other forms of Tuberculosis 8 Number of persons kept under treatment at the Middlesex County Council Disepensary, Ealing 113 Number sent to Sanatoria 37 Number sent to Hospital 13 62 Typhoid and Enteric Fever.—Three cases of typhoid and two of paratyphoid fever were notified during the year. Two of the former, one of whom died, were not confirmed by blood test and doubt existed as to the diagnosis. The remaining three cases, a woman 23 years of age suffering from typhoid, and a girl of 6| years and a woman of 73 years suffering from paratyphoid had good recoveries. The source of infection could not be found in any of the cases. Encephalitis Lethargica.—Four cases of encephalitis lethargica were notified. All affected were males. A child, three months old when attacked, lingered for several months before finally succumbing. The others, a medical student 25 years of age, a commercial traveller, 46 years, and a dress designer, 52 years, recovered. Pneumonia, Malaria and Dysentery.—During the year 57 cases of primary pneumonia, 22 cases of influenzal pneumonia, and two cases of malaria were notified. There were no cases of dysentery. The two cases of malaria had contracted the disease abroad. table IX. tuberculosis. Age Periods New Cases Deaths Pulmonary Non-Pulm'y [ Pulmonary Non-Pulm'y Male F'male Male F'male Male F'male Male F'male 0—1 — — — — — — — — 1—5 — — 2 — — — 1 1 5—10 1 2 2 2 — — 2 — 10—15 — 1 2 4 — — — — 15—20 5 5 2 — 4 3 2 1 20—25 6 4 1 2 1 4 1 25—35 14 14 2 3 4 4 — 1 35—45 8 16 2 — 4 5 — — 45—55 8 3 1 — 3 2 — — 55—65 2 1 — — 3 2 — 1 65 upwards — — — — — — — 1 Total 44 46 14 n 19 20 6 7 63 The cases of pneumonia occurred chiefly in the early and in the late months of the year, although the month of May supplied as many as 10 cases. Influenza was prevalent to some extent in the first five months of the year, during which 21 of the 22 cases of influenzal pneumonia were notified. LABORATORY WORK. The bacteriological laboratory deals with specimens taken not only in the Borough, including the Isolation Hospital, but also in the Urban Districts of Han well and Greenford. During the year the following specimens were examined:— Postive Negative Total Diphtheria: Ealing 12 392 404 Isolation Hospital 94 1168 1262 Hanwell 5 171 176 Greenford 2 4 6 Tuberculosis: Ealing 57 190 247 Hanwell 13 25 38 Greenford 1 2 3 Miscellaneous: Ealing 7 8 15 Hanwell 1 — 1 Greenford — — — Totals 192 1960 2152 DISINFECTION. During the last five years steam disinfection has been resorted to less frequently, at a great saving in cost and with no increase in the incidence of infectious disease. Steam disinfection of bed clothing is resorted to when a case of diphtheria or scarlet fever has been nursed at home, but not when the case has been removed at once to hospital. The distinction is made because in the early stages of the disease infection is confined to the close proximity of the patient and has not been permitted to penetrate deeply into the bed clothing as may occur when the case has been nursed for some weeks at home. When the case is removed to hospital the washable bed-linen and personal clothing is placed in a dilute 64 solution of disinfectant and left to be washed thoroughly, while the pillows and mattresses and any body clothing that cannot be washed are sprayed on the surface with formalin and left in the room for some hours. No treatment is applied to the walls or floors. With cases of typhoid fever, whether they are removed to hospital or nursed at home, on account of the infective discharges, steam disinfection of the bed and body clothing is carried out. The same procedure is adopted when disinfecting a room which has been occupied by a case of tuberculosis or cancer, in which cases formalin is also sprayed on the floors and walls on account of the possibility of infection being conveyed by dust. For other infectious diseases such as measles, whooping cough, etc., disinfection is only done under exceptional circumstances where a private school or other institution is involved and on these occasions the formalin spray is used for bed and body clothing and the room allowed to remain shut for some hours. During the year the following disinfections were carried out:— Rooms disinfected by formalin spray : (a) Tuberculosis 76 (b) Other infectious diseases 385 Articles disinfected by steam at Disinfector: (a) Tuberculosis 179 (b) Other infectious diseases 1,802 Articles voluntarily destroyed 138 Rooms stripped and cleansed by owner after notice served on account of dirty condition 97 MATERNITY AND CHILD WELFARE. General Arrangement.—The scheme of maternity and child welfare may be summarised as follows:— A s to the Mother. (1) Visiting of expectant and nursing mothers at their homes by Health Visitors. (2) Consultations for expectant mothers—ante-natal care— (Dr. J. W. Bell) held at the Welfare Centre on three sessions each month. 65 (3) Provision of Home Helps for necessitous mothers confined at home who require someone to look after the house and the children during the lying-in period. (4) Maternity aid, which is given in two forms, either by providing a midwife for necessitous cases when the confinement is to take place at home, or by admitting the mother to the Chiswick and Ealing Maternity Hospital towards the cost of which contributions are made according to the financial circumstances of the applicant. In both it is a requirement that any mother accepting these benefits should be seen by the Ante-Natal Consultant at the Centre. (5) Consultant aid is provided for medical practitioners who may seek the advice or assistance of the Consultant (Dr. J. W. Bell) in cases of abnormal or complicated labour. (6) Provision of milk free of charge for nursing or expectant mothers who are in necessitous circumstances. (7) Dental treatment at the School Clinic and provision of artificial dentures for expectant and nursing mothers who are unable to afford treatment privately. (8) Investigation of still-births and infant deaths by the Health Visitors to ascertain the cause and to determine if there are any measures which can be adopted by the mother in the future to prevent their occurrence. (9) Investigation of Puerperal Fever and Maternal Deaths, The former are investigated by the Health Visitors at the home and the latter are discussed with the doctors in attendance, who are always very willing to give the Medical Officer of Health the fullest information. There were six cases of puerperal fever with two deaths, giving a puerperal fever death-rate of 2.0 per 1,000 live births and one maternal death, giving a maternal death-rate of 1.0, or both combined a death-rate as a result of child-birth of 3.1 per 1,000 live births. (10) Collective instruction in hygiene and the making of clothing for babies and children at the Welfare Centre. This work is carried out by the Health Visitors who are admirably assisted, as regards the demonstrations of sewing and the making of clothing, by Mrs. Cocker, a member of the Maternity and Child Welfare Committee. 66 As to the Child. (1) Visiting of infants and children under 5 years of age at their homes by the Health Visitors. (2) Consultations for children up to 5 years of age at the Welfare Centre (Dr. Grace Banham). (3) Treatment of wasting and badly nourished children as in-patients at the Ealing King Edward Memorial Hospital. (4) Orthopaedic treatment of crippled children or those in whom crippling may result unless special treatment is provided. This form of treatment is carried out in association with the School Clinic in connection with which a scheme has been evolved by which these children are treated at the National Orthopaedic Hospital at Great Portland Street or at Stanmore and afterwards given massage at the School Clinic, the treatment being carried out under that close supervision which the treatment demands if it is to prove successful. It is hoped that by means of the scheme early and continuous treatment will be possible and that a large amount of crippling will thus be prevented. By treatment at an early age the necessity of much treatment later, when the child is of school age, will be avoided. (5) Treatment of dental caries, diseases of the naso-pharynx (enlarged tonsils and adenoids), abnormal conditions of the eyes and minor ailments is given at the School Clinic when the parents cannot afford to pay for treatment privately. Operations for circumcision are carried out at the King Edward Hospital. In all of these cases charges are made in accordance to the financial circumstances of the parents. (6) Milk is supplied free for children whose parents are in necessitous circumstances. In addition dried milk, cod liver oil, liquid paraffin and Virol are supplied at cost price to mothers. (7) The Day Nursery at Hanwell admits up to six children from Ealing. These are children of widows or unmarried mothers who have to go out to work during the day but who can care for the children at night. (8) Home nursing of cases of measles, ophthalmia neonatorum, whooping cough, poliomyelitis and epidemic diarrhoea is carried out by the Health Visitors when this is required. It is seldom, however, that their services in this respect are called for. 67 From this summary it will be recognised that two important developments have taken place in the five years from 1920 to 1925. The first is that provision has been made for maternity cases at the Chiswick and Ealing Maternity Hospital, and the second is that treatment for crippled children has been arranged for at the National Orthopaedic Hospital. The great need for the former has been evidenced by the demands for admission which are so much in excess of the accommodation that the question of making extensions will have to be considered. As to the latter the scheme has just recently been put into operation, but the beneficial effects are likely to be far reaching in the future. During the same period the Ealing Day Nursery was closed, chiefly owing to the small number of children seeking admission and the consequent high cost per child. Arrangements, however, were made for six children being admitted to the Hanwell Day Nursery. The Hostel for Unmarried Mothers was also closed, the reasons being the high cost, when there was great need for economy in public expenditure, the difficulty in management and the doubt which was expressed as to whether the keeping of these women together in one institution had a good effect on their mind and character. As regards the other work of the department there has been an extension in the way of collective instruction in hygiene to the mothers, and improvements in detail to meet increasing demands on the part of the mothers and children. As will be understood from the activities outlined above there must be co-operation with the School Medical Service and it can be said that this co-operation occurs to a very marked degree. This is greatly facilitated by the Maternity and Child Welfare Centre and the School Clinic occupying the same building which is devoted entirely to these two branches of public work. Their close proximity enables the records to be passed from the one department to the other when the child reaches school age and so renders easy the continuous treatment and supervision of abnormal or defective children throughout a period of their life during which ills, which arc apparently simple, may result, if not properly treated, in serious permanent injury to health. 68 Extremely valuable assistance has been obtained during the year from a Voluntary Committee called the Ealing Welfare Working Party formed by the Mayoress, Mrs. Kimmitt, and other ladies, two of whom, Mrs. Girdlestone and Mrs. Parry, are members of the Maternity and Child Welfare Committee. These ladies meet regularly at the Child Welfare Centre and make children's garments, from patterns supplied by the Senior Health Visitor. These are sold to the mothers at cost price or are distributed free to mothers who are in necessitous circumstances. They have also made demonstration sets of clothing to be sent to the schools for the girls to copy at their usual sewing classes under the directions of their teachers who are associating themselves with the Teachers of Domestic Subjects in giving instruction to the older girls in Infant Care and Management. Teaching of Infant Care and Management to School Girls.— Following on the issue of Circular 1353 by the Board of Education, a report was submitted on the subject to the Education Committee. This report which is printed below, was adopted by the Committee and a beginning was made in what may prove a very profitable work from the point of view of child welfare. There can be no doubt that appropriate instruction on this subject, given at the age when girls are very receptive to this kind of knowledge, will have a very lasting effect and be the means of avoiding many mistakes of the young mother during the early period of life of her baby. "report to tile education committee." "The Teaching of Infant Care and Management to School Girls. Circular of the Board of Education, 1353." "As directed by the Committee I had a conference with the Headmistresses of all the Girls' Schools and the Teachers of Domestic Subjects. "I was informed that the Teachers of Domestic Subjects have been devoting a considerable amount of attention to teaching the girls attending the Centres infant care and management, and the 69 unanimous opinion was expressed that these special teachers should continue the work in the extended form suggested by the Board of Education, since they are not only specially fitted for imparting this form of instruction but are particularly interested in it. "At present it is not possible for all the children at the appropriate age to receive instruction in domestic subjects, but when the newT centre is opened the whole of their needs will be met. It is not necessary to teach infant care in the ordinary classes in schools since all the girls reaching a suitable age will be dealt with at the Domestic Subjects Centres where infant care will form an advanced course of housecraft. By centralising the instruction in the Teachers of Domestic Subjects, overlapping will be avoided and the nature of the instruction will be more readily made to correspond with that given by the Health Visitors to the parents at the Child Welfare Centre. It is proposed that these special teachers will visit the Welfare Centre to make themselves familiar with the actual work done there so as to secure complete similarity of the instruction given to both parents and children. In addition, towards the end of their course of instruction, the girls can be brought to the Welfare Centre to see what goes on there. A visit of this character will impress on their minds the importance of infant care and will remind them where to seek advice should they require it in the future. "For teaching infant care at the Domestic Subjects Centres very little apparatus will be required. In the first place each Centre should possess a full-size life-like doll for the girls to learn to handle and dress, and in the second place each should have suitable sets of baby's and children's clothing. The Head-teachers, appreciating a useful means of instruction in sewing, have offered to have the latter made in school by the girls themselves from patterns supplied from the Child Welfare Centre so that the cost would simply be a small annual allowance for material. When the clothing gets the worse for wear by use and washing at the Domestic Subjects Centres they can be handed over to the Child Welfare Centre for distribution to necessitous mothers. "At the conference the Head-teachers showed a very real interest in the subject and gave every indication of an earnest desire 70 to assist in making this form of instruction complete and successful. I have to express my appreciation of their valuable and encouraging assistance. "THOMAS ORR, "School Medical Officer. "26th May, 1925." Infectious Conditions of Mothers and Children.—Puerperal Fever. Six cases of puerperal fever were notified in the year. One occurred in the Chiswick and Ealing Maternity Hospital, two in private Nursing Homes with doctors in attendance, three at their homes, two attended at the confinement by a doctor and one by a midwife. Three of the cases were complicated, one had albuminuria, one was in feeble health previous to the confinement and one was an abnormal prsentation requiring surgical interference. One case was admitted to the Isolation Hospital, and two to the West Middlesex Hospital; two were treated in private nursing homes and one at home. Two deaths occrured. Ophthalmia Neonatorum.—During the year six cases of ophthalmia neonatorum were notified. All the cases were mild in character and were treated at home with most satisfactory results, the eyesight in all being unimpaired. Two of the cases were attended by a doctor at birth and four by a midwife who afterwards called in a doctor. Measles and Whooping Cough.—These diseases are not notifiable under the Infectious Disease Notification Act, but in the weekly returns supplied by the head-teachers of the public elementary schools valuable information is obtained of the actual cases occurring amongst school children. This information calls attention to other cases in younger members of the same family. Measles occurred in a mild form in the early part of the year, but no deaths resulted. Whooping cough on the other hand was less prevalent but caused three deaths, the death-rate from whooping cough being 0.04 per 1,000 of the population. This rate is low compared with the rates from England and Wales and London, which were respectively 0.15 and 0.19 per 1,000 population. The measles death-rate for England and Wales and London were respectively 0.13 and 0.08 compared with the entire absence of deaths in Ealing. 71 Pemphigus Neonatorum.—In November an outbreak of pemphigus neonatorum was experienced at the Chiswick and Ealing Maternity Hospital. Until the end of December, 16 children had been affected. All except two of the children were very mildly attacked, and there was nothing beyond a few characteristic spots to indicate that anything was amiss with them. The two cases attacked more extensively than the others were, however, scarcely incommoded and both recovered completely after about 14 days. The Hospital was closed on the 10th November after the initial crop of cases when nine were affected. Thorough disinfection was carried out and the hospital was re-opened on the 24th November. Cases began to occur again on the 5th December and continued intermittently until the end of the year in spite of all precautions and repeated disinfection. Closure of the hospital was not repeated, but affected cases were removed immediately to a special ward at the. Isolation Hospital, which adjoins. After the end of December cases occurred in an unexpected and disconcerting manner in spite of all precautions until the 6th April when the cases ceased. Altogether 32 cases occurred, 16 to the end of December and 16 to the 6th April. The disease appears to be very infectious and therefore difficult to eradicate when once it gets into an institution. The following is a Summary of the Work of the Welfare Centre during the Year. Number of children on register at the end of year 1,427 Mothers visiting Centre for the first time 784 Children visiting Centre for the first time 784 Total attendances made by mothers 5,576 Total attendances made by children 6,447 Average attendance of mothers each afternoon 38 Average attendance of children each afternoon 44 Number of Consultations by Medical Officer 2,535 Average number of children seen by Medical Officer each afternoon 18 Children referred to School Clinic for treatment: Nose and Throat 2 Eyes 9 Teeth 13 72 Mothers referred for dental treatment to School Clinic 15 Mothers supplied with artificial dentures 4 Children referred to King Edward Hospital for minor operations 34 Children admitted to King Edward Hospital as indoor patients 2 Children referred to special London Hospitals 21 Mothers attending Ante-Natal Clinic: First Visits 245 Re-visits 87 Number of Consultations by Consultant at Centre 332 Mothers referred to King Edward Hospital 21 Aid provided for mothers at confinement: Consultant aid—cases 5 Medical aid—cases 6 Midwives—cases 13 Home Helps—cases 26 Dried Milk supplied at costprice Value £395 11 11 Virol supplied at cost price „ £104 12 5 Cod Liver Oil supplied at cost price „ £79 16 10 Number of Maternity Cases admitted to the Chiswick and Ealing Maternity Hospital 233 Amount received for Treatment at Maternity Hospital £876 3 9 Expectant or Nursing Mothers receiving a supply of milk free of charge 607 Children under 5 years of age receiving a supply of milk free of charge 556 The following is a Summary of the Work of the Health Visitors. Visits to children under 12 months: First Bisits 823 Return Visits 2,170 Visits to children 1 to 5 years of age 3,171 Visits to expectant mothers 236 Visits to children or mothers attending the Welfare Centre 1,463 Visits to investigate infant deaths and still-births 54 Special visits or investigations 257 Visits to cases of Ophthalmia Neonatorum 21 Visits to cases of Puerperal Fever 6 73 Visits to cases of Measles and Whooping Cough 366 Visits to cases of Tuberculosis 10 Visits to cases of Scarlet Fever on discharge from the Isolation Hospital 93 Other Visits 9 Total Visits 8,659 Interviews, etc. 2,475 THOMAS ORR, M.D., P.Sc., Medical Officer of Health. May 31st, 1926. Borough of Ealing. EDUCATION COMMITTEE. REPORT of the School Medical Officer. For the Year ended 31st December, 1925. 76 EDUCATION GENERAL PURPOSES SUB-COMMITTEE, 1924-25 (Which deals with the School Medical Service). Chairman— Councillor G. R. Weeks. Vice- Chairman— Councillor A. H. Chilton, J.P. Alderman H. Armriding, Councillor W. J. S. Cox, Councillor J. C. Fuller, Councillor H. M. Sayers, Councillor W. J. Sturgess. Councillor W. T. White. Miss F. M. Coombe. Miss A. D. Hawkin, Miss C. G. Wilson, LX.A. Mr. R. G. HaylES. Mr. F. L. Jermyn, Mr. L. Marsh, M.A. Rev. C. J. Sharp, M.A. -77STAFF. School Medical Officer— Thomas Orr, M.D., D.Sc.. Of the Middle Temple, Barrister-at-Law. Assistant School Medical Officer and School Oculist— Harold Ellis, M.B., B.S., M.R.C.S., Iv.R.C.P., D.P.H. School Nurses— *†‡Hilda Bailey (Senior). *‡Annie Johnson. *Mary McGann. Clerks— †Mercie Richardson. Grace Such. Surgeon— E. A. Chill, M.D., C.M. Anaesthetist— S. M. Banham, M.B., M.R.C.S., L.R.C.P. Dentists— L. Brown, L.D.S., R.C.S. (Eng.). I. Cohen, L.D.S., R.C.S. (Eng.). School Clinic. 13, Mattock Lane, Ealing, W. *Certificate as Trained Nurse. †Certificate of Royal Sanitary Institute, School Nurse and Health Visitor ‡Certificate of Central Midwives Board. —78- CO-ORDINATION. The co-ordination of the work of the School Medical Service is so complete that all forms of treatment made available for school children at the School Clinic or otherwise are made available for children under 5 years of age. Children under school age requiring treatment for dental conditions, diseases of the naso-pharynx, abnormal conditions of the eye, minor ailments and for crippling or conditions which may result in crippling, are passed over to the School Clinic for appropriate treatment. The records of defective or debilitated children who reach school age are handed over as a routine procedure to the School Clinic so that medical supervision can be continued. This co-ordination is greatly facilitated by the School Clinic and the Maternity and Child Welfare Centre occupying the same building, which is devoted entirely to these two branches of public health work. THE SCHOOL MEDICAL SERVICE IN RELATION TO PUBLIC HEALTH. School Hygiene. The Education Committee has under its control twelve public elementary schools which embrace twenty-four departments; seven for boys, seven for girls, seven for infants, one for boys and girls, one for girls and infants, and one for junior boys and girls. During the year the Grange School, consisting of one department for boys and girls, was opened to replace the Joseph Lancaster School, which was closed. The Grange School, a plan of which was represented in last year's Annual Report, is constructed so that it can be used, when the weather permits, as an open-air school. It is hoped that the teachers will value this special characteristic of this new school and will use the classrooms as open-air classrooms whenever practicable. The decision of the Committee to go on with the erection on this site of another block of the same character for junior boys and girls is commendable. When this block has been completed, St. Mary's Girls' School and the Good Shepherd Hall Temporary -79- School for Infants can be closed. Proposals for the alteration and improvement of St. Saviour's School are maturing and it is hoped that these will be carried out in the course of the present year. Of the rest of the schools, Christ Church is most urgently in need of improvements to bring it up to a reasonably hygienic tandard. Attention was drawn during the year to the insanitary condition of the urinals at the Infants' and Boys' Departments of St. John's School. The Borough Surveyor has put forward definite suggestions with regard to their improvement, which it is hoped will be accepted and acted upon by the Managers. Seven of the schools are of comparatively modern construction dating from 1905 to 1911. Six are old and fall short to a greater or less extent of modern requirements and one is a temporary school which has already been mentioned. In the modern schools the cloakrooms are very satisfactory and are heated by hot water pipes, although no special arrangements are made for the drying of children's clothes and boots. Children do not have to travel long distances from their homes to the school and there is no necessity for children to partake of meals in the schools save in exceptional cases or on rare occasions. Medical Inspection. Medical Inspection during the year embraced the following groups:— (1) Routine Inspection as required by the Board of Education as follows:— (a) Entrants.— All children admitted to school during the year. (b) Intermediates.— All children eight years of age or reaching that age before the end of the year. (c) Leavers.— Children who are 12 or who will be 12 before the end of the year, together with those over that age not previously examined. —80— (2) Non-routine Inspections as follows:— (a) Children not in the aforementioned routine groups who are presented by the head-teachers for examination for some defect or suspected defect. (b) Children requiring supervision on account of some defect found at a previous routine or non-routine examination. (c) Childrer sent to the School Clinic by the head-teachers, attendance officers or school nurses for examination for some defect or suspected defect. (3) Annual Inspections at the schools or at the School Clinic of (a) Physically defective or crippled children (b) Mentally defective children. In the following tables are indicated the total number of children medically inspected in a routine manner. It will be seen that they include 696 entrants, 605 intermediates and 446 leavers, making the total routine inspections 1,747, or 27.3 per cent, of the children on the school registers. Number of Children Inspected. School Entrants i i Total Boys Girls Provided. Drayton 57 64 121 Lammas 70 30 100 Little Ealing 87 64 151 Northfields 24 26 50 North Ealing 38 42 80 Good Shepherd Hall (temporary) 25 34 59 Non-provided. St. Saviour's 40 43 83 St. John's 32 20 52 Total 373 323 696 -81 Number of Children Inspected. School. Intermedi ites Leavers Boys Girls Total Boys Girls Total Provided. Drayton 46 41 87 6 14 20 Grange 13 6 19 27 22 49 Ealing Central — — - 44 70 114 Lammas 37 36 73 — — — Little Ealing 65 50 115 32 61 93 Northfields 51 42 93 15 18 33 North Ealing 17 19 36 2 4 6 Good Shepherd Hall (temporary) 32 14 46 — — — Non-Provided. Christ Church 3 32 35 31 27 58 St. Saviour's 22 24 46 — — — St. John's 15 26 41 20 3 23 St. Mary's 8 6 14 2 48 50 Total 309 296 605 179 267 446 The non-routine inspections included 422 children re-examined on account of some defect previously found and eight new cases presented by the head-teachers for examination at school on account of some defect or suspected defect. At the School Clinic there were examined 977 children who had been referred by the head-teachers, school attendance officers, and school nurses for examination and out of this number 355 children attended for further examination. Altogether, 3,509 children attending the public elementary schools were examined or re-examined during the year. The total number of children on the school registers was 6,380 and the average number in attendance 5,455, the average attendance therefore being 85.5 per cent. Taking the number of children medically examined as 3,509 it means that 55 per cent, of the children on the registers were medically examined during the year. The attendance of parents at the routine inspections was very good. As many as 78 per cent, of all the inspected children were accompanied by at least one parent. —82— Findings of School Medical Inspection. Review of the Facts Disclosed. Table II gives the total number of defects discovered on inspection at the schools during routine medical examination and at the School Clinic. Among 1,747 routine children examined there were 605 defects requiring treatment and 205 requiring to be kept under observation without treatment; and among 1,762 children specially examined there were found 875 defects requiring treatment and 241 requiring to be kept under observation. Thus out of a total of 3,509 children there were altogether 1,480 defects requiring treatment, and 446 requiring observation. Of the 1,747 children examined in the routine way 366, or 20.9 per cent, were found to require treatment for defective conditions other than uncleanliness and dental disease. (a) Uncleanliness.— In accordance with the practice in previous years, the heads of all the girls attending the elementary schools were inspected after the usual school holidays, three times a year, to determine their condition as regards cleanliness. Of 9,387 children examined, 245, or 2.6 per cent., were excluded on account of verminous condition. In addition, seven other children were excluded for verminous condition at the routine medical inspection held in the schools and 26 at the School Clinic on being referred for examination by the head-teachers. In the ordinary course of events summonses are issued under the School Attendance Bye-laws if children so excluded are not cleansed within fourteen days. During the year only one summons was required, a fine of 10s. being imposed by the Justices. No action was taken during the year under Section 87 of the Education Act of 1921, the procedure under the School Attendance Bye-laws being considered more satisfactory. -83 The following Table shows an appreciable improvement in the cleanliness of the children during the last two years :— Year i\uniDer oi Children Examined of Verminous Condition Number of Children Excluded Percentage Summons Issued 1923 8,247 418 5.0 33 1924 9,591 329 3.4 2 1925 9,387 245 2.6 1 The standard of cleanliness is being made higher every year. A condition calling for exclusion now would not have been visited with exclusion several years ago. The improvement in cleanliness is therefore much greater than the figures indicate. (b) Minor Ailments.— The minor ailments found at routine and non-routine inspections were as follows:— Ringworm of Head 24 Ringworm of Body 18 Scabies 6 Impetigo 177 Minor Injuries 10 Other Skin Diseases 138 Ear Diseases (including Otorrhoea) 58 Eye Disease (including Blepharitis and junctivitis) 47 Total 478 (c) Enlarged Tonsils and Adenoids.— At the routine inspection 46 children were found with enlarged tonsils, nine with adenoids, twelve with enlarged tonsils and adenoids and five with —84— other conditions of the nose or throat of such a degree as to demand treatment, and 83 children were found with these conditions of such a mild character as to require to be kept under observation only. In addition, 24 cases of enlarged tonsils, five cases of adenoids, eight cases of enlarged tonsils and adenoids and two of other diseases requiring treatment, and six cases of these conditions requiring to be kept under observation were found at the School Clinic, where they had been submitted for special examination at the instance of the teachers or school nurses. (d) Tuberculosis.— Six suspected cases of pulmonary tuberculosis requiring treatment were found on routine inspection, and four definite cases of pulmonary tuberculosis requiring treatment and eighteen suspected cases requiring to be kept under observation were discovered as the result of inspection at the School Clinic. In addition one case of glandular tuberculosis requiring treatment was detected at the School Clinic. A number of delicate children are at periodic intervals seen at the School Clinic and kept under close supervision. In many of these cases there is a bad family history of tuberculosis. They are examined and weighed regularly and when they fail to respond to improved hygienic conditions they are referred to the Tuberculosis Officer for further observation and treatment. (e) Diseases of the Skin.— At the routine inspection there were discovered seven cases of impetigo and twelve other conditions of the skin. The cases met with at the School Clinic, to which they had been specially referred for examination, were as follows:— Ringworm of Head 24 Ringworm of Body 18 Scabies 6 Impetigo 170 Other Conditions 126 Total 344 -85 (/) External Eye Disease.— Five cases of blepharitis, one of conjunctivitis, ten of squint and two of other conditions were observed on routine inspection; and five cases of blepharitis, thirteen of conjunctivitis, eight of squint and twenty-one of other conditions were found in children referred to the School Clinic. (g) Defective Vision.— During routine inspection 89 children were found to have such a degree of defective vision that they were recommended for special examination by an Oculist. At the School Clinic 70 cases of the same character were referred for a similar examination. (h) Ear Disease and Defective Hearing.— Seven cases of defective hearing, four of otitis media and four other conditions of the ear were found in the course of routine school medical inspection. At the School Clinic four cases of defective hearing, 27 of otitis media and twelve of other conditions were met with. (i) Dental Defects.— The first table which follows classifies the dental defects found at the routine medical inspection. In this table it will be seen that of the entrants 47.8 per cent, had sound teeth, of the intermediate group 44.3 per cent., and of the leavers no less than 74.0 per cent, had sound teeth. Dental Inspection, 1925. Entrants Intermediates Leavers Total All teeth sound : No. of Children 333 268 330 931 Percentage 47.8 44.3 74.0 53.3 Less than 4 teeth decayed : No. of Children ... 196 209 96 501 Percentage 28. 1 34.5 21.5 28.6 Four and more than 4 teeth decayed : No. of Children 167 128 20 315 Percentage 24.0 21.1 4.4 18.0 —86— Dental Inspection, 1915 to 1925. Year Entrants Intermediate Group Leavers Total Percentage with sound Teeth Percentage with sound Teeth Percentage with sound Teeth Percentage with sound Teeth 1915 23.0 26.2 35.7 27.0 1916 15.6 30.2 37.2 25.3 1917 21.7 25.9 41.1 28.8 1918 28.8 25.8 44.1 32.8 1919 36.9 32.2 60.6 42.7 1920 48.6 46.4 64.2 53.1 1921 58.4 64.0 76.5 66.6 1922 45.7 50.2 72.8 56.3 1923 55.2 52.5 80.5 63.9 1924 55.0 58.5 78.0 65.0 1925 47.8 44.3 74.0 53.4 In the second table the percentages of children in the three medical inspection groups for the year 1925 are compared with those in previous years. The year 1925 shows some deterioration in all three groups, though fortunately this is not so great with the leavers as with the other two groups. This deterioration is difficult to account for. The amount of dental treatment at the School Clinic has been maintained at the same level as in previous years and it can only be surmised that there has been some remissness on the part of the children in caring for the teeth and on the part of the parents in supervising them. This view is borne out by the fact that the entrants themselves have shown deterioration from previous years. In January, 1925, the Board of Education in Circular 1347 drew attention to a leaflet prepared by the Dental Board of the United Kingdom for the guidance of teachers in public elementary and secondary schools in instructing their pupils as to the need of taking care of the teeth and as to the way in which this should be done, and stated that the Dental Board offered to supply copies of this leaflet for distribution to all teachers. The Education Committee accepted this offer and issued instructions to the teachers to make use of these leaflets in instructing the children in the care of the teeth. Later in the year, July, a circular letter was issued -87— to the head teachers drawing their attention to the actual condition of the teeth of the children in the various schools as indicated by the percentage of children found on medical inspection to have sound teeth in each group and pointing out the need for greater educational efforts to bring about a further improvement by giving suitable instruction based on the Dental Board's leaflet on the care and preservation of the teeth. It is hoped that the constant reiteration of the need for care of the teeth will cause greater interest to be taken in the subject by the children and parents alike. (j) Crippling Defects.— There were at the end of the year 51 elementary school children on the list of crippled children. Two of these were in special residential schools and 49 were attending elementary schools in the Borough. No cases were kept at home. This list is an accurate and complete one as every physically defective child not on the school list of crippled children must be reported by the head-teachers to the School Medical Department at once and every crippled child of school age not admitted to school must be reported by the school enquiry officers. The list is kept accurate by the submission of all crippled children to medical examination once a year as a routine procedure. Some, however, may be medically examined oftener to determine the progress of the defect, the desirability of further or special treatment and the need for special or restricted exercises in school. INFECTIOUS DISEASE. Through the returns of cases of non-notifiable infectious disease furnished weekly by the head-teachers, it was ascertained that during the year the number of children absent from school as actual cases of, or contacts with non-notifiable infectious disease were 1,073 due to measles, 375 to whooping cough, 203 to chickenpox and 429 due to mumps. These weekly returns not only give fairly accurate information as to the prevalence of infectious disease in the schools, but enable visits to be made to the homes of the children affected by the health visitors, who give advice on the care and nursing, particularly of the children suffering from measles and whooping cough under five years of age, in whom Complications of a serious character are so apt to occur, —88— Under the Elementary Education Provisional Code, 1922, Amending Regulations No. 2, 1924, the School Medical Officer certified that the fall in attendance below 60 per cent, was attributable to the prevalence of epidemic illness in three schools, two on account of influenza and the third on account of measles. Children to the number of 194 were excluded during the year under Article 53 of the Education Code for the following conditions: Conjunctivitis 9 Impetigo 139 Ringworm of the Head 19 Ring. worm of the Body 10 Scabies 6 Other Skin Diseases 11 Total 194 During routine inspections considerable use is made of the facilities offered by the Public Health Laboratory. Swabs are taken from all sore throats and suspicious conditions of the nose and ear and submitted to bacteriological examination. When deemed advisable the children are excluded from school pending the result of the report. In a number of suspected cases of ringworm, samples of hair were taken for examination. FOLLOWING UP. After medical inspection of the children in a school, two copies of a form giving a list of defective children are sent to the Headteacher. The head-teacher is asked, when ten weeks have elapsed, to enter on one copy whether or not the children have received treatment. This copy is sent to the School Medical Officer and the other copy is retained for reference but preserved as confidential. By this means the school nurses are saved unnecessary visits when the defect noted does not require immediate treatment, and the head-teachers are kept informed of the physical condition of the children and are encouraged to consider their physical condition in relation to their educational progress. (b) Tonsils and Adenoids.—In Table IV it will be seen that 55 cases of enlarged tonsils or adenoids were operated upon at the School Clinic, and that ten cases were dealt with at hospitals or by private practitioners. At the School Clinic there were also treated seven cases of other abnormal nasal conditions. (c) Tuberculosis.—Three school children suffering from active tuberculosis of the lungs were admitted to Sanatoria, and three children with doubtfully active tuberculous glands were allowed to attend school but under particular supervision. Of the 24 children suspected of suffering from pulmonary tuberculosis, fourteen were referred to the Tuberculosis Officer for his special observation. —89— Special lists are made of all the children requiring treatment of the teeth, eyes, nose or throat which can be provided at the School Clinic. These cases are followed up by the school nurses and treatment is advised. All other cases in which treatment is advisable or in which observation is required, are visited in rotation by the school nurses, when advice to obtain treatment is given or directions regarding hygienic supervision are repeated. During the year the school nurses made 1,666 visits regarding defective children. MEDICAL TREATMENT. (a) Minor Ailments.— In Table IV are tabulated the number and nature of the minor ailments which received treatment during the year. It will be noted that 379, or 79 per cent., were treated at the School Clinic, and 99, or 20.7 per cent., by private practitioners or at hospitals. The total attendances at the School Clinic for the daily treatment of minor ailments were as follows:— Ear Cases 820 Eye Cases 912 Dressings 13 Ringworm 110 Impetigo 2,267 Scabies 14 Others 1,134 Total 5,270 —90— (d) Skin Diseases.— The cases of diseases of the skin which were treated are shown in Table IV where it is indicated that of 373 children referred for treatment 299 were treated at the Clinic and 74 otherwise. During the year 24 cases of ringworm of the head were found. Seventeen of these were treated by means of X-Rays by Dr. Arthur, the treatment in all cases being successful, and the children being allowed to return to school in about a month after. Impetigo furnished 177 cases, of which 146 were treated at the School Clinic. Only three cases of scabies were discovered during the year and the cure of these cases was quickly effected. (e) External Eye Disease.— The children referred for external eye disease numbered 47, of whom 32 were treated at the School Clinic. The diseases included ten cases of blepharitis, fourteen of conjunctivitis and twenty-three other conditions. (/) Defective Vision.— During the year 177 children were referred for the testing of refraction. The School Oculist examined 192 children with errors of refractio:1., and twenty were examined by private practitioners or at hospitals and two were dealt with otherwise. Glasses were prescribed and supplied in 170 of the cases attending the Clinic. All children provided with glasses are kept under supervision, and their eyesight is re-tested periodically. In the case of children referred to the Oculist and found to be suffering from lesser degrees of myopia or short sight, all reading at home and home lessons are prohibited and the head-teachers are instructed to see that these children do no near work at school. Children with high degrees of myopia are taught orally. Printed instructions are being issued to parents and head-teachers with regard to the care of these short-sighted children. Eighteen cases of squint came under observation. Most cases of squint develop at about the age of three years. A number of these are referred to the Oculist from the Child Welfare Centre and when suitable glasses are worn there is a fair prospect of the squint being cured. A number of parents, however, cease to take —91— their children to the Child Welfare Centre when they reach the age of eighteen months to two years. If these children develop squint they often do not come under supervision until they commence school life. By this time the chances of curing the squint is greatly impaired. These children at a later date are frequently referred to an Ophthalmic Hospital to have the eyes straightened by an operation. Even then the sight in the squinting eye is, as a rule, greatly reduced. It is unfortunate that parents do not generally realise the importance of obtaining early treatment for this condition. (g) Ear Disease and Hearing.— Of 58 cases which received treatment, 48 were treated at the School Clinic. These were mostly cases of otorrhoea. Head-teachers are instructed to place children with defective hearing in the front row of their classes. Serious defects of hearing are fortunately not frequent and there is no need to arrange a special class for children so affected. (h) Dental Defects.— Table IV, Group IV, shows that 4,312 children, or a total of 67.5 per cent, of those on the school register, were dentally inspected during the year. Of these, 2,869 were found to require treatment and 1,786 were actually treated at the School Clinic, 468 receiving further treatment during the year. The extractions numbered 371 permanent and 2,147 temporary teeth. For the purpose of these extractions gas was administered on 51 occasions. Fillings were applied to 1,676 permanent teeth and 16 temporary teeth. Twenty-three cases of dental deformity were referred to the Royal Dental Hospital for special treatment. These were chiefly cases of serious irregularity or of defective bite which are capable of great improvement if treated early by special extractions or regulative apparatus. The Education Committee by contributing to the funds of the Hospital are able to secure tickets entitling the children to this special orthodontic treatment. —92— All children on being admitted to school for the first time are dentally inspected at about the same time that the usual medical inspection of the entrants is carried out at the same school. Treatment is then offered at the School Clinic and when once treatment has been given the child is dentally inspected and, if necessary, dentally treated once every year. In this way a child may be kept under continuous dental supervision and treatment throughout its whole school life. Steps are being taken to insist on treatment being carried out in those children whose parents refuse the facilities offered at the Clinic. Some parents, and fortunately they are few in number, promise to have their children treated privately, and unless treatment is insisted upon by repeated and persistent visits from the school nurses, the promise is not fulfilled. So far only the worst cases have been threatened with proceedings under the Children Act, but the time has now come for insisting upon treatment in all but the mildest cases of dental defect. (i) Crippling Defects and Orthopaedics.— In previous years it was left to the parents to take their children who required orthopaedic treatment to London Hospitals, the only provision made by the Local Education Authority being for massage and remedial treatment at the Ealing King Edward Memorial Hospital. It must be admitted that in many instances the treatment was far too late in being sought, and that repeated visits at the hospital for supervision and treatment were made in an haphazard and irregular fashion, consequently the results were not as satisfactory as they might have been. Moreover, attendance at school was irregular and the education of the child materially suffered. The constant supervision by the school medical staff, and especially the medical examination of each crippled child at least once a year, was of great benefit, yet the results were far from satisfactory. A letter from the Board of Education in 1924, stating that the Managers of the National Orthodaepic Hospital, Great Portland Street, were considering the extension of their provision for orthopaedic treatment at Stanmore and that they would be willing to undertake the treatment of crippled children sent there by Local Education Authorities in the neighbourhood, caused the whole question to be considered, with the result that a scheme, outlined in the report here printed, was adopted with one modification —93— suggested later by the Board of Education. This modification was that a Surgeon from the Orthopaedic Hospital should visit the Clinic once a month to examine the children and advise as regards further operative and remedial treatment. The cost of this addition was estimated to be £3 3s. Od. each month or £34 13s. Od. in the year "Report to the General Purposes Education Sub-Committee. Physically Defective Children." "As requested, I have considered the question of evolving a scheme by which treatment at the National Orthopaedic Hospital, Great Portland Street and Stanmore, may be made available for all physically defective children attending the public elementary schools. "At present the treatment of physically defective childrenis haphazard and irregular. In some instances a mother may take her child at an early age to a suitable hospital and attend for treatment regularly as advised by the surgeon, but usually what happens is that the child is taken to hospital too late to obtain the best results, the attendance is not regular and the child may remain away from school for long periods out of control and suffering educationally. "In a suitable scheme the object is to get the crippled child under proper treatment at the earliest possible opportunity, to see that the child attends hospital when requested to do so and to make the after-treatment, including massage, which is all important as readily available as possible, "The scheme suggested is that cases should be referred by the School Medical Officer to the National Orthopaedic Hospital, Great Portland Street. A report on each case would be forwarded from the hospital to the School Medical Officer pointing out the treatment advised. If an operation be required the child would go to the Orthopaedic Hospital at Stanmore, where the necessary surgical treatment would be given and where the child's education would be continued under special teachers— a very essential part of the scheme. When no operation is called for and massage is necessary, this would be given at the School Clinic by a specially trained nurse sent down from the National Orthopaedic Hospital. This nurse would not only give massage treatment but would be —94— able to say when the child should return to hospital to be seen again by the surgeon who would determine when any further operation is desirable. Subsequent operations may be necessary so that careful supervision is essential. Should electrical treatment be required the child could attend the hospital at Great Portland Street. "During the whole treatment the children would be kept under the supervision of the School Medical Officer and his staff, who could see that the children regularly attend the Hospital or School Clinic. It is important to note that with this scheme the provision of a school for Cripples would be avoided. "For the purpose of estimating the cost of the proposals, I have considered in detail all the crippled children coming within our supervision. There are 51 altogether. Two children are at special schools. Three are at home, two being cases of tuberculosis of the spine, both of which are nearly fit for school, and one being a physically and mentally defective case about to go into a special school. Of the remaining 46 physically defective children all are receiving or have received some form of treatment. At the present time of these 46 cases six may benefit from operative treatment, fourteen do not require operative treatment but may require it in the near future,eleven may benefit from massage while the remainder require little or no treatment. "It is extremely difficult to say how many would require operative treatment in the year, but it may be about 20 altogether. I estimate, however, that to begin with, about half only would come within the scheme, as some of the parents would prefer to continue treatment at the hospitals already attended. As six weeks is the average stay of each case in hospital this means that during the year 60 hospital weeks at £2 2s. Od. a week, or £126, would be the cost of the operation cases. For massage, allowing two visits of the nurse each week, on 44 school weeks at 12s. a visit (10/6 as fee and 1/6 as train fare), the cost would be £52 16s. Od. Three massage treatments a week are advised for some cases, but as a beginning it might be desirable to see how much the services of the nurse are taken advantage of. The only other expenditure would be a couch for the children while under treatment at the Clinic. 95— " Thus the total cost would be:— £ s. d. Operative treatment 126 0 0 Massage treatment 52 16 0 Couch 10 0 0 Total £188 16 0 "It has to be noted that the arrangements for massage made with the King Edward Memorial Hospital would be discontinued. The amount estimated for this treatment last year was £30. Thomas Orr, Medical Officer. 24th February, 1925. The scheme only came into operation in September, 1925, and there has not been much time to get it working fully. Many of the crippled children were already attending London Hospitals and parents were not easily persuaded to send their children to the National Orthopaedic Hospital— neither was a change desirable in many cases— but it may be said that by means of this scheme children are now being sent for treatment at a much earlier stage than formerly and the treatment is more regular and sustained. (j) Heart Disease.— When a child attending school is found to be suffering from heart disease, drilling and all vigorous games are prohibited. The parents are also advised with regard to the mode of life which the child should adopt at home. Heart disease in children, due in the vast majority of cases, to rheumatism, is responsible for a great deal of crippling in later life. A number of school children on medical inspection are found to present some slight variation from the normal in the condition of their hearts. A searching enquiry is made in these cases for a history of rheumatism, especially in its more insidious forms, and the activities of these children are restricted for twelve months. The parents are also put on their guard. At the end of this period a fair proportion of these children can be safely regarded as normal The remainder continue with their restrictions under supervision. —96— Special record cards of all heart cases are made out and particular notes are made of their progress each year. All cases are examined at least once in every year. In most cases there is very little if anything to call attention to the condition of the child and it is only on medical examination that valvular heart affection is discovered. Considerable attention has recently been drawn to heart disease in children in the medical press and suggestions have been made for the treatment and after care of children affected and especially with regard to prevention. As regards prevention guidance is given by the history of rheumatism in the father or mother for there seems to be a distinct hereditary tendency to rheumatism. Where there is a history of rheumatism parents should be instructed to exercise a particular care over their children, especially in avoiding exposure to cold and dampness, to view with concern any occurrence of joint or "growing" pains in members of their families and to have them medically examined. With the exercise of care many cases of valvular heart disease pass through life without much inconvenience from the condition of the heart, but on the other hand severe strain either by excessive exertion or by an acute illness may cause such a failure of function that the life of the individual is in constant danger. Fortunately severe cases of heart disease are comparatively infrequent in school children and it is therefore but seldom that special residential care is required. Most cases attend school without any unusual symptoms or loss of attendance, but a small proportion (in Ealing seven out of a total of 93) shows susceptibility to extremes of heat and cold or are affected by the school routine or pressure. In such cases a limited attendance at school is permitted or residence in a Special Home or School is recommended. One particular case was sent during the year to a Special, School for three months, as a result of which he returned to the ordinary elementary school at which he has since been in regular attendance. The subject of heart disease in children is one which calls for investigation both as to the intimate cause and its prevention. Until we have the full and exact knowledge it seems we should devote our attention to the children generally in eliminating possible sources of infection, say from the teeth and naso-phaynx —97— and in treating those who are anaemic and poorly nourished, and particularly by keeping under supervision those children in whose family there is a history of rheumatism. In the public elementary schools there are at present 93 children suffering from valvular disease of the heart, all of whom are kept under regular supervision. Only seven cases can be said to require special supervision on account of subjective symptoms or impaired health which lessen their ability to take full advantage of their education. (k) Payments for Treatment.— The following amounts have been received during the year for the treatment of children at the School Clinic. £ s. d. Dental Treatment 59 18 0 Throat Operations 13 16 6 Spectacles 46 4 11 X-Ray Treatment for Ringworm of Head 2 8 0 Treatment at Royal Dental Hospital 2 5 6 Other Payments from Maternity and Child Welfare Committee, Homes for Motherless Children, etc. 17 3 3 Total £141 16 2 OPEN AIR EDUCATION. Play-ground classes are being developed in most of the schools and every encouragement is given for their development. The Grange School, which was opened during the year, is constructed, as was pointed out in the Annual Report for 1924, so that all the class-rooms can be opened completely on the side abutting on the verandah and made into open-air class-rooms. This special characteristic has beer to a large extent taken advantage of by the teachers whenever the weather has been favourable, but as time goes on and the teachers and children get more accustomed to open-air conditions the maximum use will be made of it. —98— PHYSICAL TRAINING. Whenever special exercises are required for defective children, such as those suffering from round shoulders or heart disease, instructions are issued to the head-teachers, who see that the instructions are acted upon. Round shoulders call for special shoulder exercises and heart disease for restricted exercises of a less active character than those indulged in by normal children. No organiser of physical training has been appointed. PROVISION OF MEALS. No meals are provided for school children under Section 82-86 of the Education Act. Seldom are children discovered who would benefit from the provision of meals at school, but when they are discovered steps are taken by voluntary means to have some form of meal supplied to them. SCHOOL BATHS. Baths are not provided at any of the schools but at the Public Baths there is set aside one swimming bath for the separate use of the school children. All children in the upper classes, boys and girls, attend regularly as part of their physical training and receive instruction from skilled teachers. There is every evidence that this form of physical training is much more enjoyed than the usual gymnastic exefcises given in the playground. The sense of freedom, the feeling of progress from day to day and the spirit of rivalry, which this progress engenders, together help in making this form of exercise enjoyable and at the same time beneficial from the aspect of health. CO-OPERATION OF PARENTS. The parents are encouraged in every way to attend the medical inspection in the schools and when they do not attend a visit of the school nurse, in the case of a defective child, encourages the mother to take an interest in the child's health. Another way in which the parents are encouraged to watch over the health of their children is by facilitating their bringing the children to the School Clinic whenever they are not making progress or whenever some —99— abnormality in health of a chronic character arises, concerning which advice can be given or for which treatment may be received at the Clinic. Among the conditions concerning which advice is sought in this way are anaemia, chronic cough, heart disease, nasal catarrah, adenoids or enlarged tonsils, defective vision, dental caries and minor ailments. When a mother wishes to take her child to the Clinic, all she has to do is to tell the teacher who gives her a f6rm to present at the Clinic which is open for such medical examinations on any school da}r at 10 o'clock. In this way, as much as in any other, mothers have been taught to appreciate the value of medical inspection and particularly the need for early treatment, and, still more, the value of hygiene in the prevention of ill-health. At routine inspection in the schools as many as 85 per cent. of the entrants, 78 per cent. of the intermediates, and 67 per cent. of the leavers were accompanied by at least one parent CO-OPERATION OF TEACHERS. Constant assistance and active co-operation are afforded by the teachers in the scheme of school medical work, not only at the actual inspection in the schools but in the following up of defective children and in seeing that medical treatment is obtained. In most cases the head-teacher is present at the medical inspection when seme previous history of a child can be given to the medical inspector or when the head-teacher can receive advice as to the care and supervision of a child in school. The form sent to each headteacher after medical inspection indicating the defective children in the individual schools is most useful in facilitating the co-operation of the teachers, who are kept informed of the physical progress of each child and are able to ascertain from the parents if treatment has been obtained or to urge the necessity of treatment in those cases which require it. The assistance of the teachers is most marked in the ascertainment of mentally and physically defective children, in selecting those children who should be examined at the School Clinic for defective vision, defective teeth, enlarged tonsils and adenoids, —100— and in submitting for examination other children who should be kept under supervision, such as cases of heart disease, anaemia and chest conditions. There can be no question that the teachers recognise the importance of the medical service in the educational scheme and that they take an intimate interest in the child's health in relation to its educational curriculum and progress. CO-OPERATION OF SCHOOL ATTENDANCE OFFICERS. The two School Attendance or Enquiry Officers continue to act in intimate co-operation with the school medical staff to whom they give invaluable assistance in the discovery of physically and mentally defective children at an early stage, whether in attendance at school or not, and in their supervision. Frequently they refer to the Clinic for examination children whose continued absence from school is due to some condition for which no treatment is being obtained or for which treatment or supervision at the School Clinic is desirable. Both School Enquiry Officers appear to recognise the important inter-relation of school medical and school attendance work. CO-OPERATION OF VOLUNTARY BODIES. Although most of the supervision of defective children is carried out by the permanent staff of school nurses, with much assistance afforded by the head-teachers and the school enquiry officers, yet there are ways in which considerable assistance is obtained through voluntary agencies. The Central Aid Society is able to assist in obtaining hospital and particularly convalescent home treatment for anaemic or badly nourished children and in supplying surgical appliances for those who are crippled ; the National Society for the Prevention of Cruelty to Children in bringing pressure to bear on parents who neglect their children either in the way of general care or medical treatment; the School Attendance Aid Committee in providing boots or surgical apparatus and the Middlesex King Edward Memorial scheme in giving holidays at their Holiday Home at Heme Bay for anaemic or badly nourished children. —101— NURSERY SCHOOLS. There are no nursery schools in the district. Children under 5 years of age are admitted to the Infants' Departments whenever, in the opinion of the School Attendance Committee, it is desirable because the children cannot be properly cared for at home on account of the mother having to go out to work or on account of some other circumstance militating against proper care at home during the ordinary school hours. Very few married women are engaged in regular employment in the district and consequently there is little demand for a special nursery school. SECONDARY SCHOOLS. Secondary Schools, one for boys and one for girls, have been provided by the Middlesex Education Committee in Ealing. The school for girls was opened during the year under review. Medical inspection is carried out by the Ealing School Medical Department, but the report on this inspection is submitted to the Middlesex Education Committee. BLIND, DEAF, DEFECTIVE AND EPILEPTIC CHILDREN. The school enquiry officers report to the school medical department all children of school age who are blind, deaf, defective or epileptic and not in attendance at any school; head-teachers similarly report at once defective children admitted to school and, further, the staff of the Maternity and Child Welfare Centre pass on the records of all defective children on reaching the age of five years. In these ways a fairly complete list of specially defective children is kept. Blind and deaf children are promptly dealt with by being sent to special residential schools. One blind girl and four blind boys are being maintained by the Local Education Authority at Certified Schools for the Blind. Six boys and four girls who are considered partially blind from high myopia attend public elementary schools under supervision. These myopic children, concerning whom special instructions are given to the teachers and parents, are examined by the Oculist at regular intervals. —102— Nine deaf mutes, two boys and seven girls, are maintained at Special Schools. All backward children at school, who are more than two years behind those of the same chronological age, are examined once in each year. Those who are classed as feeble-minded are placed on a special list to be kept under particular medical and educational supervision. Imbeciles are notified at once to the Local Control Authority. Should a feeble-minded child prove to be troublesome or difficult to control, he or she is sent to a Special Residential School. The others, who are usually the high-grade defectives, attend the public elementary schools where they receive great consideration on the part of both the teachers and the normal children. They are discouraged from leaving school until they are 16 years of age unless the parents car. show that a suitable occupation has been found for them. It is surprising how well seme of these feeble-minded children do in simple occupations. When they do leave before the age of 16 years they are kept under the supervision of the Inspector under the Juvenile Employment Committee. On reaching that age the Local Control Authority is informed so that the supervision can be continued. There are at present 22 feeble-minded children attending public elementary schools and none are kept at home. Three children, two girls and one boy, are maintained at Residential Special Schools. The provision of Special Day Schools for mentally defective children, who are at present attending public elementary schools, remains for the future consideration of the Committee. Special Schools are very costly and it would be especially costly to provide for such a small number of children as there is to be dealt with in this area. Moreover, the ultimate advantages of their special education are, relatively speaking, so small that at a time when economy must be exercised the provision of a costly special school cannot be undertaken lightly. But if a special school must ultimately be provided it appears that it would be better and more economically provided by a combination of Local Education Authorities in this part of the county. —103— EMPLOYMENT OF CHILDREN AND YOUNG PERSONS. Only 136 boys and girls of school age are employed outside school hours in accordance with the Bye-laws with respect to the Employment of Children. The nature of the employment is indicated as follows:— Boys. Girls. Errands 86 Errands 12 Milk Round 14 Nurse Maid 2 Newspaper Round 13 Cleaning Steps 1 House Work 6 Shop Boy 1 Filling Coal Bags 1 121 15 All these children were medically inspected during the year and two were found to be in such a condition of health that their employment was discontinued. Thirty-three of the above children were found to be employed without being registered under the Bye-laws. A warning was given by the Inspector to the parents and employers of these children. The Juvenile Employment Committee solicits and receives the co-operation and assistance of the School Medical Department. Records are given to the Committee of the previous medical history of all juveniles coming within their notice and advice is given with regard to the employment of defective children. MISCELLANEOUS. Under this heading are noted all examinations carried out at the School Clinic. At the School Clinic are examined all children specially referred by the Education Committee, Head-teachers and School Enquiry Officers, and also teachers newly appointed by the various Education Sub-Committees or School Managers. —104— Children can be submitted for examination at the School Clinic on each school day at 10 o'clock. Those usually submitted are children suspected of having verminous heads or bodies, or having ringworm, scabies or impetigo, or those whose examination is desirable on account of some defect or suspected defect, such as defective eyesight, disease of the eye, ear, nose and throat, which may require treatment. In fact, any defective child not under medical care may be submitted by the head-teachers for examination. The examinations carried out during the year may be summarised as follows:— Verminous children 652 Impetigo 325 Scabies 45 Ringworm 36 Teachers 20 Children for Holiday Home, King Edward Memorial Scheme 9 Miscellaneous 892 Total 1,979 STATISTICAL TABLES. The Statistical Tables required by the Board of Education are appended. THOMAS ORR, May 25//*, 1926, School Medical Officer. —105— TABLE I. A.—Routine Medical Inspections. Number of Code Group Inspections:— Entrants 696 Intermediates 605 Leavers 446 Total 1,747 Number of other Routine Inspections — B.—Other Inspections. Number of Special Inspections 985 Number of Re-Inspections 777 Total 1,762 —106— TABLE II. A. RETURN OF DEFECTS FOUND BY MEDICAL INSPECTION IN THE YEAR ENDED 31st DECEMBER, 1925. DEFECT OR DISEASE. Routine Inspections Special Inspections No. of Defects. No. of Defects. Requiring Treatment. Requiring to be kept under observation, but not requiring Treatment. Requiring Treatment Requiring to be kept under observation, but not requiring Treatment (1) (2) (3) (4) (5) Malnutrition 3 2 1 - Uncleanliness, 7 - - - (See Table IV., Group V.) — — - — Skin Ringworm, scalp — — 24 — body — — 18 — Scabies - — 6 — Impetigo 7 — 170 — Other Diseases (non-Tuberculous) 12 — 126 — Eye Blepharitis 5 — 5 — Conj uncti vitis 1 —. 13 — Keratitis - — 1 - Corneal Opacities - - 3 - Defective Vision (excluding Squint) 89 - 70 - Squint 10 — 8 - Other Conditions 2 — 17 - Ear Defective Hearing 7 2 4 - Otitis Media 4 — 27 -. Other Ear Diseases 4 - 12 3 Nose and Throat Enlarged Tonsils only 46 74 24 - Adenoids only 9 3 5 - Enlarged Tonsils and Adenoids 12 — 8 - Other Conditions 5 6 2 6 Enlarged Cervical Glands (non-Tuberculous) ... ... 4 50 4 - Defective Speech — 1 - 2 Teeth Dental Diseases (See Table IV., Group IV.) 315 - 196 - Heart and Heart Disease:— Organic 1 25 - 67 Circulation Functional _ 1 - 12 Anaemia 7 8 8 87 Lungs Bronchitis 14 - 7 6 Other Non-Tuberculous Diseases 1 — - — Pulmonary: Tuberculosis Definite - — 4 - Suspected 6 — - 18 Non-Pulmonary : Glands — — 1 - Spine — — - — Hip — — - — Other Bones and Joints - — - - Skin - — - — Other forms - - - - Nervous System Epilepsy — — _ 1 Chorea — — 6 — Other Conditions — — — — Deformities Rickets — 1 — — Spinal Curvature 5 4 1 — Other Forms 18 16 - 39 Other Defects and Diseases 11 12 104 — Total 605 205 875 241 —107— B— Number of Individual Children found at Routine Medical Inspection to require Treatment (excluding Uncleanliness and Dental Diseases). Group. Numbkr or Children. Percentage of Children found to require Treatment. Inspected. Found to require Treatment. (1) (2) (3) (4) Code Groups:— Entrants 696 209 30.0 Intermediat es 605 77 12.7 Leavers 446 80 18.0 Total (Code Groups) 1747 366 20.9 Other Routine Inspections — — — —108— TABLE III. RETURN OF ALL EXCEPTIONAL CHILDREN IN THE AREA. Boys Girls Total Bllind (including partially blind) (i.) Suitable for training in a School or Class for the totally blind. Attending Certified Schools or Classes for the Blind 4 1 5 Attending Public Elementary Schools - - - At other Institutions - — — At no School or Institution - — — (ii.) Suitable for training in a School or Class for the partially blind. Attending Certified Schools or Classes for the Blind - - - Attending Public Elementary Schools 6 4 10 At other Institutions — — — At no School or Institution — — - Deaf (including deaf and dumb and partially deaf) (i.) Suitable for training in a School or Class for the totally deaf or deaf and dumb. Attending Certified Schools or Classes for the Deaf 2 7 9 Attending Public Elementary Schools - - - At other Institutions - — — At no School or Institution - — — (ii.) Suitable for training in a School or Class for the partially deaf. Attending Certified Schools or Classes for the Deaf - - - Attending Public Elementary Schools - - - At other Institutions - — — At no School or Institution - — - Mentally Defective Feebleminded (cases not notifiable to the Local Control Authority.) Attending Certified Schools for Mentally Defective Children 1 2 3 Attending Public Elementary Schools 9 13 22 At other Institutions - — - At no School or Institution — — - Notified to the Local Control Authority during the year. Feebleminded 1 — 1 Imbeciles — — — Idiots 1 — 1 Epileptics Suffering from severe epilepsy. Attending Certified Special Schools for Epileptics - - - In Institutions other than Certified Special Schools - - - Attending Public Elementary Schools - - - At no School or Institution — — — Suffering from epilepsy which is not severe Attending Public Elementary Schools 1 - 1 At no School or Institution — —— — —109—  Boys Girls Total Physicau/y Defective Infectious pulmonary and glandular tuberculosis. At Sanatoria or Sanatorium Schools approved by the Ministry of Health or the Board 1 2 3 At other Institutions — — — At no School or Institution — — — Non-infectious but active pulmonary and glandular tuberculosis. At Sanatoria or Sanatorium Schools approved by the Ministry of Health or the Board - - - At Certified Residential OpenAir Schools - - - At Certified Day Open-Air Schools - - - At Public Elementary Schools 3 — 3 At other Institutions — — — At no School or Institution — — — Delicate children (e.g., pre- or latent tuberculosis, malnutrition, debility, anaemia, etc.) At Certified Residential Open-Air Schools At Certified Day Open-Air Schools At Public Elementary Schools 128 71 199 At other Institutions — — — At no School or Institution — — — Active non-pulmonary tuberculosis. At Sanatoria or Hospital Schools approved by the Ministry of Health or the Board - - - At Public Elementary Schools — — — At other Institutions — — — At no School or Institution - - - Crippled Children (other than those with active tuberculous disease), e.g., children suffering from paralysis, etc., and including those with severe heart disease. At Certified Hospital Schools - — — At Certified Residential Cripple Schools ... 2 - 2 At Certified Day Cripple Schools - - - At Public Elementary Schools 19 30 49 At other Institutions - — — At no School or Institution - - - —110— TABLE IV. RETURN OF DEFECTS TREATED DURING THE YEAR ENDED 31st December, 1925. TREATMENT TABLE. Group 1.—Minor Ailments (excluding Uncleanliness. for which see Group V.) Disease or Defect. Number of Defects treated, or under treatment during the year. Under the Authority's Scheme. Otherwise. Total. (1) (2) (3) (4) Skin:— Ringworm— Scalp 17 7 24 Ringworm— Body 13 5 18 Scabies 3 3 6 Impetigo 146 31 177 Other Skin Diseases 5 — 5 Minor Eye Defects (external and other, but excluding cases falling in Group II.) 32 15 47 Minor Ear Defects 48 10 58 Miscellaneous (e,g. minor injuries, bruises, sores, chilblains, etc. 115 28 143 Total 379 99 478 —111— Group II.—Defective Vision and Squint (excluding Minor Eye Defects treated as Minor Ailments—Group I.). Defect or Disease. No. of Defects dealt with. Under the Authority's Scheme. Submitted to refraction by private practitioner or at hospital, apart from the Authority's Scheme. Otherwise. Total. (1) (2) (3) (4) (5) Errors of Refraction (including Squint) (Operations for squint should be recorded separately in the body of the Report) 170 20 2 192 Other Defect or Disease of the Eyes (excluding those reported in Group 1) - - - - Total 170 20 2 192 Total number of children for whom Spectacles were prescribed:— (a) Under the Authority's Scheme 170 (b) Otherwise Total number of children who obtained or received Spectacles:— (a) Under the Authority's Scheme 170 (b) Otherwise Group III.—Treatment of Defects of Nose and Throat. Number of Defects. Received Operative Treatment. Received other forms of Treatment. Total number treated. Under the Authority's Scheme, in Clinic or Hospital. By Private Practitioner or Hospital, apart from the Authority's Scheme. Total. (1) (2) (3) (4) (5) 55 10 65 7 72 —112— Group IV.—Dental Defects. (1) Number of Children who were:— (a) Inspected by the Dentist: Aged: Routine Age Groups 5 410 Total 4,312 6 407 7 360 8 465 9 569 10 498 11 514 12 407 13 425 14 \ 257 Specials 196 Grand Total 4,508 (b) Found to require treatment 2,869 (c) Actually treated 1,786 (d) Re-treated during the year as the result of periodical examination 468 (2) Half-days devoted to — Inspection 28 Treatment 198 Total 226 (3) Attendances made by children for treatment 2,056 (4) Fillings:— Permanent teeth 1,676 Temporary teeth 16 Total 1,698 (5) Extractions:— Permanent teeth 371 Temporary teeth 2,147 Total 2,518 (6) Administrations of general anaesthetics for extractions 315 (7) Other operations:— Permanent teeth — Temporary teeth — Group V.—Unceanliness and Verminous Conditions. (1) Average number of visits per school made during the year by the School Nurses 3 2) Total number of examinations of children in the Schools by chool Nurses 9,387 (3) Number of individual children found unclean 245 (4) Number of children cleansed under arrangements made by the Local Education Authority — (5) Number of cases in which legal proceedings were taken:— (a) Under the Education Act, 1921 — \b) Under School Attendance Byelaws 1